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TREATMENT  OF  DISEASE 


WILCOX 


BY  THE  SAME  AUTHOR. 


Pharmacology  and  Therapeutics.  A  Text-Book  for 
Physicians  and  Students  of  Medicine  and  Pharmacy. 
Seventh  Edition.     Octavo;  ix  -f-  885  pages. 

Cloth,  $3.50. 

"The  book  in  its  present  form  will  be  even  more  popular  than 
before." — Therapeutic  Gazette. 

"  It  is  fortunate  that  the  author  is  not  only  an  active  practitioner 
of  medicine  but  a  clinical  teacher  of  physicians,  fully  alive  to  their 
special  needs." — Post-Graduate,  New  York. 

Materia  Medica  and  Pharmacy.  A  Text-Book  for 
Physicians  and  Students  of  Medicine  and  Pharmacy. 
Seventh  Edition.     Octavo;  ix  -t- 490  pages. 

Cloth,  $2.50. 

"  It  would  indeed  be  difl&cult  to  lay  one's  hand  on  a  book  more 
admirably  adapted  to  the  purposes  for  which  it  is  intended." — Ther- 
apeutic Record,  Louisville. 

A  Manual  of  Fever  Nursing.  A  Text-Book  for  Nurses, 
Based  upon  a  Course  of  Lectures  delivered  to  the 
Nurses  of  St.  Mark's  Hospital,  etc.  Illustrated. 
Second  Edition.     Duodecimo;  229  pages. 

Cloth,  $1  00. 

It  IS  a  timely  work  and  full  of  good  suggestions,  useful  to  pa- 
tients, nurses,  and  to  physician^  alike." — St.  Louis  Medical  and  Sur- 
gical Journal. 

P.  BLAKISTON'S  SON  &  CO. 

PHILADELPHIA 


THE 

"  ■'  •  J 

TREATMENT  OF  DISEASE  \' 

A  MANUAL  OF 

PRACTICAL  MEDICINE 


BY 

REYNOLD  WEBB  WILCOX,  M.A.,  M.D.,  LL.D. 

PROFESSOR    OF    MEDICINE    AT    THE    NEW    YORK    POST    GRADUATE    MEDICAL    SCHOOL    AND   HOSPITAL; 
CONSULTING    PHYSICIAN    TO    THE    NASSAU    HOSPITAL;    VISITING     PHYSICIAN     TO     ST.     MARK's 

hospital:    fellow    of   the    American    academy    of    medicine     member    of   the 
american  therapeutic  society  and  of  the  american  medical  association  j 

permanent     member     of     THE     MEDICAL     SOCIETY    OF    THE    STATE    OF    NEW 

YORK  :      HONORARY     MEMBER     OF     THE     CONNECTICUT     STATE     MEDICAL 

SOCIETY;    VICE-CHAIRMAN    OF  THE    REVISION    COMMITTEE  OF  THE 

UNITED    STATES     PHARMACOPCEIA,    ETC. 


SECOND   EDITION,   REVISED 


PHILADELPHIA 
BLAKISTON'S   SON   &   CO, 

1012   WALNUT   STREET 
1909 


First  Edition,  Copyright,  March,  1907,  By  P.  Blakiston's  Son  &  Co. 

Second  Edition,  Copy'right,  November,  1907,  By  P.  Blakiston's  Son  &  Co. 

Reprinted,  March,  1909.  ' 


Printed  by 

The  Maple  Press 

y'ork.  Pa. 


TO 
THK  MEMORY  OF 

MY   GRANDFATHER, 

REYNOLD  WEBB,  M.  D., 

AND  MY  UNCLE, 

DANIEL  MEIGS  WEBB,  A.M.,  M.D., 

THIS  VOLUME  IS  DEDICATED. 


PREFACE  TO  SECOND  EDITION. 


The  short  time  which  has  elapsed  since  the  appearance  of  the  first  edition 
of  this  work  has  not  been  marked  by  any  important  advances  in  medicine 
which  necessitate  radical  changes  in  this  treatise.  The  opportunity  offered 
has  been  employed  to  thoroughly  revise  the  literary  style,  correct  unavoidable 
errors,  make  more  specific  statements  in  regard  to  treatment  and  to  add  new 
matter  upon  mountain  and  tick  fevers,  blastomycotic  infections,  methyl 
alcohol  intoxication,  indicanuria,  compressed  air  disease  and  the  trembles. 


Vll 


PREFACE  TO  FIRST  EDITION 


Twenty-three  years'  experience  in  teaching  more  than  ten  thousand 
medical  graduates  has  impressed  upon  the  author  that  the  practitioner 
desires  especially  the  latest  views  upon  questions  of  diagnosis  and  methods 
of  treatment.  Under  the  influence  of  Post  Graduate  Schools  the  medical 
student  is  more  thoroughly  grounded  in  diagnosis,  and  particularly  in  physical 
diagnosis,  than  formerly.  There  still  remains  an  anxious  endeavor  on  the 
part  of  the  physician  to  increase  his  knowledge  of  therapeutics,  whether 
physical,  medicinal  or  dietetic,  which  goes  to  make  up  what  may  be  termed  the 
management  of  a  patient  suffering  from  disease.  Wliile  aetiology  is  important, 
pathology  is  interesting  and  a  sound  basis,  and  diagnosis  is  essential,  it  is 
from  a  thorough  and  broad  knowledge  of  therapeutics  in  its  larger  sense  that 
the  practitioner  will  achieve  his  greatest  success  and  win  his  most  enduring 
reputation  among  his  patients  and  the  public  at  large.  The  therapeutic 
awakening  which  is  now  being  experienced,  shows  that  more  to-day,  than  ever 
before,  is  expected  of  the  clinician.  With  the  practical  needs  of  the  physician 
always  in  view,  this  book  has  been  written.  To  Dr.  Henry  Hubbard  Pelton, 
Instructor  in  Medicine  at  the  New  York  Post  Graduate  Medical  School  and 
Hospital,  and  Chief  of  Medical  Clinic,  Presbyterian  Hospital  Dispensary, 
who  has  diligently  collected  his  lectures  during  the  sessions  of  1904-7,  who 
has  filled  the  lactincB  inseparable  to  clinical  teaching  and  who  has  borne  the 
labor  of  proof-reading  and  index-making,  the  author  would  tender  his  heart- 
felt acknowledgment  of  his  varied  and  valuable  services. 


IX 


TABLE  OF  CONTENTS. 


PREFACE. 
INTRODUCTION. 

I. 

THE  INFECTIOUS  DISEASES. 

Enteric  Fever 7 

Paratyphoid  Fever 28 

Mountain  Fever 29 

Intermittent  Tick  Fever 32 

Typhus  Fever 33 

Malta  Fever 37 

Relapsing  Fever 39 

Yellow  Fever 42 

Influenza 47 

Dengue 51 

Malarial  Fevers 54 

Nasha  Fever 63 

Cholera 64 

Dysentery 70 

Catarrhal  Dysentery 71 

Tropical  Dysentery 72 

Amoebic  Dysentery 73 

Diphtheritic  Dysentery 76 

Epidemic  Gangrenous  Proctitis 80 

Hill  Diarrhoea 81 

Sprue 82 

The  Plague 84 

Climatic  Bubo 86 

Diphtheria 87 

Mumps 97 

Whooping  Cough 99 

Cerebrospinal  Fever 104 

Erysipelas iii 

Acute  Articular  Rheumatism 114 

xi 


xii  TABLE    OF    CONTENTS. 

Septicaemia;  Pyaemia 120 

Hydrophobia 123 

Tetanus 127 

Anthrax 131 

Glanders i34 

Actinomycosis 136 

Blastomycosis i37 

Epidemic  Stomatitis 138 

Milk  Sickness 140 

Gonorrhoeal  Infections 141 

Syphilis i45 

Tuberculosis 156 

Acute  Miliary  Tuberculosis 158 

Acute  General  Miliary  Tuberculosis 159 

Acute  General  Tuberculosis  of  Pulmonary  Form 160 

Acute  General  Tuberculosis  of  Meningeal  Form 161 

Pulmonary  Tuberculosis 161 

Acute  Pneumonic  Pulmonary  Tuberculosis 161 

Chronic  Pulmonary  Tuberculosis 162 

Fibroid  Phthisis 169 

Tuberculosis  of  the  Lymphatic  Glands 184 

Tuberculosis  of  the  Pleura 186 

Tuberculosis  of  the  Peritonaeum 186 

Tuberculosis  of  the  Pericardium 187 

Tuberculosis  of  the  Kidney 188 

Tuberculosis  of  the  Pelvis  of  Kidney-  Ureter  and  Bladder 188 

Tuberculosis  of  the  Testicles,  Prostate  Gland  and  Seminal  Vesicles.  189 

Tuberculosis  of  the  Ovaries,  Uterus  and  Fallopian  Tubes 189 

Tuberculosis  of  the  Mammary  Gland 190 

Tuberculosis  of  the  Heart  and  Blood-vessels 190 

Acute  Infectious  Pneumonia 190 

Bronchopneumonia 198 

Chronic  Interstitial  Pneumonia 203 

Embolic  Pneumonia 205 

Haemorrhagic  Infarct  of  the  Lung 205 

Septic  Embolic  Pneumonia , 205 

Beriberi 205 

Mycetoma 209 

Febricula 210 

Protracted  Idiopathic  Continued  Fever 211 

Weil's  Disease 212 

Glandular  Fever 212 


TABLE   OF    CONTENTS.  Xlll 

Miliary  Fever 213 

Japanese  River  Fever 214 

Tick  Fever 215 

Trypanosomiasis 216 

Kala-Azar 217 

Kubisagari 218 

Leprosy 219 

Framboesia 222 

Verruga 223 

Measles 225 

Rubella 229 

Scarlatina 231 

Fourth  Disease 239 

Varicella 240 

Smallpox 242 

Vaccinia 253 

II. 
CONSTITUTIONAL  DISEASES. 

Gout 256 

Purinaemia 263 

Diabetes  Mellitus 265 

Diabetes  Insipidus 273 

Chronic  Rheumatism 276 

Muscular  Rheumatism 278 

Arthritis  Deformans 280 

Obesity 284 

Scurvy 287 

Infantile  Scurvy 290 

Rickets 291 

III. 

THE  INTOXICATIONS,  INCLUDING  THE  EFFECTS  OF 
EXPOSURE  TO  HIGH  TEMPERATURES. 

Lead  Poisoning 297 

Arsenical  Poisoning 301 

Mercurial  Poisoning 303 

Antimonial  Poisoning 305 

lodism 306 

Bromism 306 

Borism 307 


XIV  TABLE    OF    CONTENTS. 

Alcoholism 308 

Acute  Alcoholism 308 

Chronic  Alcoholism 310 

Delirium  Tremens 313 

Methyl  Alcohol  Poisoning 315 

Chloralism 317 

Sulphonmethane  (Sulphonal)  Poisoning 318 

Sulphonethylmethane  (Trional)  Poisoning 318 

Veronal  Poisoning 319 

Morphinism    319 

Haschisch  Poisoning 322 

Cocainism 322 

Tobacco  Poisoning 323 

Carbon  Bisulphide  Poisoning 324 

Lacquer  Poisoning 324 

Food  Poisoning 325 

Grain  Poisoning 326 

Ergotism 326 

Pellagra 327 

Lathyrism 328 

Atryplicism 329 

The  Effects  of  Exposure  to  High  Temperatiures 329 

Heat  Exhaustion 329 

Sun-stroke 330 

IV. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM  AND  PERITONEUM. 

DISEASES  OF  THE  MOUTH  AND  TONGUE. 

Mycotic  Stomatitis ^7,7, 

Gangrenous  Stomatitis 334 

The  Geographical  Tongue 335 

Leucoplakia  Buccalis 336 

DISEASES  OF  THE  SALIVARY  GLANDS. 

Ptyalism 337 

Dry  Mouth 337 

Acute  Parotitis 337 

Ludwig's  Angina 338 

DISEASES  OF  THE  TONSILS  AND  PHARYNX. 

Acute  Catarrhal  Pharyngitis 338 

Acute  Follicular  Tonsillitis 340 

Quinsy  Sore  Throat 342 


TABLE    OF    CONTENTS.  XV 

DISEASES  OF  THE  (ESOPHAGUS. 

Acute  (Esophagitis 343 

Chronic  Catarrhal  (Esophagitis 344 

(Esophageal  Spasm 344 

Cancer  of  the  (Esophagus 344 

Benign  Stricture  of  the  (Esophagus 345 

Dilatations  of  the  (Esophagus 346 

DISEASES  OF  THE  STOMACH. 

Acute  Catarrhal  Gastritis 347 

Chronic  Catarrhal  Gastritis 350 

Phlegmonous  Gastritis 356 

Traumatic  and  Toxic  Gastritis 356 

Diphtheritic  Gastritis 357 

Mycotic  Gastritis 357 

Gastric  Ulcer 358 

Cancer  of  the  Stomach 369 

Hypertrophic  Stenosis  of  the  Pylorus  ' 373 

Gastric  Dilatation 374 

Acute  Gastric  Dilatation 377 

Hour-glass  Stomach 378 

Visceroptosis 379 

Neuroses  of  the  Stomach 382 

Hyperchlorhydria 382 

Hypochlorhydria 385 

Cardiospasm 386 

Pylorospasm 387 

Gastric  Hyperperistalsis .  388 

Merycismus 388 

Nervous  Eructation  of  Gas 389 

Gastric  Hyperaesthesia 389 

Gastralgia ! 390 

Bulimia 391 

Anorexia  Nervosa 392 

Cyclic  Vomiting 392 

Hffimatemesis 393 

DISEASES  OF  THE  INTESTINE. 

Simple  Acute  Catarrhal  Enteritis 394 

Chronic  Catarrhal  Enteritis 396 

Cholera  Morbus 400 


XVI  TABLE   OF    CONTENTS. 

Diarrhoeas  of  Children 402 

Acute  Gastro-enteritis 402 

Cholera  Infantum 404 

Acute  Entero-colitis 406 

Pseudo-membranous  Entero-colitis 408 

Phlegmonous  Enteritis 409 

Haemorrhagic  Infarct  of  the  Bowel 409 

Ulceration  of  the  Bowel 410 

Ulcer  of  the  Duodenum 410 

Primary  Tuberculous  Ulceration  of  the  Intestine 411 

Embolic  Ulcer  of  the  Intestine 412 

Syphihtic  Ulcer  of  the  Intestine 412 

Appendicitis 412 

Intestinal  Obstruction 417 

Enteroptosis 424 

Constipation 424 

Colitis '. 428 

Dilatation  of  the  Colon 429 

Nervous  Affections  of  the  Intestine 429 

Malignant  Growths  of  the  Intestine 432 

Proctitis 433 

Haemorrhoids 433 

DISEASES  OF  THE  LIVER. 

Abnormalities  in  Shape  and  Position  of  the  Liver 435 

Perihepatitis 437 

Abscess  of  the  Liver 438 

Cirrhosis  of  the  Liver 442 

The  Fatty  Liver 45° 

The  Amyloid  Liver 45 1 

Syphilis  of  the  Liver , 452 

Acute  Yellow  Atrophy  of  the  Liver 454 

Neoplasms  of  the  Liver 456 

Cancer  of  the  Liver 45^ 

Parasites  of  the  Liver 460 

Echinococcus  Disease  of  the  Liver 460 

Other  Parasites  of  the  Liver 463 

DISEASES  OF  THE  HEPATIC  BLOOD-VESSELS. 

Anaemia  and  Hyperaemia  of  the  Liver 463 

Thrombosis  and  Embolism  of  the  Portal  Vein 465 


TABLE    OF    CONTENTS.  XVll 

DISEASES  OF  THE  BILIARY  TRACT. 

Jaundice 466 

Acute  Catarrhal  Jaundice 466 

Toxic  Jaundice 470 

Icterus  Neonatorum 471 

Acute  Cholecystitis 471 

Cholelithiasis 473 

Neoplasms  of  the  Gall-bladder 481 

Neoplasms  of  the  Gall  Ducts 482 

Stenosis  of  the  Gall  Ducts 482 

Parasites  of  the  Gall  Ducts 483 

DISEASES  OF  THE  PANCREAS. 

Acute  Pancreatitis 483 

Acute  Haemorrhagic  Pancreatitis 484 

Acute  Suppurative  Pancreatitis 484 

Acute  Gangrenous  Pancreatitis 485 

Chronic  Pancreatitis 486 

Tumors  of  the  Pancreas 487 

Cancer  of  the  Pancreas 487 

Cysts  of  the  Pancreas 488 

Pancreatic  Calculi 489 

DISEASES  OF  THE  PERITONiEUM. 

Acute  Peritonitis .  489 

Chronic  Peritonitis 494 

Neoplasms  of  the  Peritonaeum 496 

Ascites 497 

V. 

DISEASES  OF  THE  BLOOD. 

The  Anaemias 500 

Secondary  Anaemia 500 

Primary  or  Essential  Anaemias 503 

Chlorosis 503 

Progressive  Pernicious  Anaemia 507 

Leucaemia 511 

Leucanaemia 516 

Chloroma 516 

Chronic  Cyanosis 517 

Anaemia  Infantum 517 


XVIU  TABLE    OF    CONTENTS. 

Purpvira 518 

Arthritic  Purpura 519 

Purpura  Haemorrhagica 520 

Hsemorrhagic  Diseases  of  the  New-born 521 

Haemophiha 522 

VI. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

DISEASES  OF  THE  SPLEEN. 

The  Wandering  Spleen 525 

Perisplenitis 526 

Splenitis 526 

Abscess  of  the  Spleen 526 

Rupture  of  the  Spleen 527 

The  Amyloid  Spleen 527 

Neoplasms  of  the  Spleen 527 

Echinococcus  Cysts  of  the  Spleen 528 

Splenic  Anaemia 528 

Banti's  Disease 529 

Pseudo-leucaemia 529 

Status  Lymphaticus 532 

DISEASES  OF  THE  THYROID  GLAND. 

Simple  Goitre 534 

Congestion  of  the  Thyroid  Gland 536 

Acute  Thyroiditis 536 

Exophthalmic  Goitre 536 

Myxoedema 541 

Neoplasms  of  the  Thyroid  Gland 545 

DISEASES  OF  THE  THYMUS  GLAND. 

Hypertrophy  of  the  Thymus  Gland 546 

Thymus  Death 546 

Atrophy  of  the  Thymus  Gland 546 

Haemorrhage  into  the  Thymus  Gland. 546 

Abscess  of  the  Thymus  Gland 546 

Neoplasms  of  the  Thymus  Gland 546 

Tuberculous  Inflammation  of  the  Thymus  Gland 546 

DISEASES  OF  THE  SUPRARENAL  GLAND. 

Addison's  Disease 547 


TABLE    OF    CONTENTS.  XIX 

vn. 

DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS. 

DISEASES  OF  THE  PERICARDIUM. 

Acute  Pericarditis ". 550 

Chronic  Adhesive  Pericarditis 555 

Hydropericardium 556 

Haemopericardium 556 

Pneumopericardium 556 

Calcification  of  the  Pericardium , . .  556 

DISEASES  OF  THE  MYOCARDIUM. 

Cardiac  Hypertrophy 556 

Cardiac  Dilatation 559 

Cardiac  Atrophy 562 

Myocarditis 562 

Parenchymatous  Myocarditis 562 

Fatty  Myocarditis 565 

Fatty  Infiftration  of  Heart 565 

Fibrous  Myocarditis 566 

Acute  Suppurative  Myocarditis 568 

Aneurysm  of  the  Heart 568 

Rupture  of  the  Heart 568 

DISEASES  OF  THE  ENDOCARDIUM. 

Acute  Endocarditis -. 569 

Simple  Acute  Endocarditis 569 

Malignant  Endocarditis 569 

Chronic  Endocarditis 574 

Mitral  Insufficiency 575 

Mitral  Obstruction 577 

Aortic  Insufficiency 579 

Aortic  Obstruction 582 

Tricuspid  Insufficiency 583 

Tricuspid  Obstruction 584 

Pulmonic  Insufficiency 585 

Ptdmonic  Obstruction 585 

Combined  Valvular  Lesions 586 

Congenital  Cardiac  Defects 586 

The  Neuroses  of  the  Heart 598 

Palpitation 598 

Tachycardia 599 


XX  TABLE    OF   CONTENTS. 

Bradycardia 599 

Arrhythmia 600 

Angina  Pectoris 603 

DISEASES  OF  THE  BLOOD-VESSELS. 

Arteriosclerosis 606 

Aneurysm 610 

Aneurysm  of  the  Thoracic  Aorta 611 

Aneurysm  of  the  Abdominal  Aorta 615 

Aneurysm  of  the  Branches  of  the  Abdominal  Aorta 616 

VIII. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

DISEASES  OF  THE  NOSE. 

Acute  Rhinitis 620 

Hay  Fever 621 

DISEASES  OF  THE  LARYNX. 

Acute  Catarrhal  Laryngitis 623 

Simple  Chronic  Catarrhal  Laryngitis 624 

Spasmodic  Laryngitis 626 

Tuberculous  Laryngitis 627 

(Edema  of  the  Glottis 629 

DISEASES  OF  THE  TRACHEA  AND  BRONCHI. 

Acute  Bronchitis 630 

Chronic  Bronchitis 634 

Fibrinous  Bronchitis .^ 636 

Spasmodic  Bronchitis 638 

Bronchiectasis 641 

DISEASES  OF  THE  LUNGS. 

Pulmonary  Emphysema 644 

Syphilis  of  the  Lung   650 

Neoplasms  of  the  Lung 651 

Hydatid  Disease  of  the  Lung 652 

Abscess  of  the  Lung 652 

Gangrene  of  the  Lung 654 

DISEASES  OF  THE  PLEURA. 

Acute  Fibrinous  Pleurisy 656 

Acute  Serous  Pleurisy 658 

Empyema 663 

Chronic  Adhesive  Pleurisy 666 

Hydrothorax 667 

Hydropneumothorax  and  Pyopneumothorax 667 


TABLE    OF    CONTENTS.  XXI 

Haemothorax 669 

Neoplasms  of  the  Pleura 669 

DISEASES  OF  THE  MEDIASTINUM. 

Carcinoma  and  Sarcoma  of  the  Mediastinum 670 

Non-malignant  Neoplasms  of  the  Mediastinum 672 

Abscess  of  the  Mediastinum 672 

Simple  Lymphadenitis  of  the  Mediastinum 672 

Indurative  Mediastino-pericarditis 6*^2 

Mediastinal  Emphysema 673 

IX, 

DISEASES  OF  THE  URINARY  SYSTEM. 

Anomalies  of  the  Kidney 674 

The  Movable  Kidney 675 

Albuminuria 677 

Functional  Albuminuria 678 

Acute  Congestion  of  the  Kidney 679 

Chronic  Congestion  of  the  Kidney 679 

Uraemia 681 

Acute  Nephritis 684 

Chronic  Parenchymatous  Nephritis 691 

Clironic  Arterial  Nephritis 696 

The  Amyloid  Kidney 702 

Suppurative  Nephritis,  Pyelonephrosis  and  Pyelitis 704 

Hydronephrosis 707 

Paranephritis 710 

Nephrolithiasis 711 

Neoplasms  of  the  Kidney 716 

The  Cystic  Kidney 718 

Idiopathic  Hematuria .  719 

Haemoglobinuria 720 

Toxic  Haemoglobinuria 721 

Paroxysmal  Haemoglobinuria 721 

Chyluria 722 

Indicanuria 723 

X. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

DISEASES  INVOLVING  CHIEFLY  THE  BRAIN  AND  ITS  MEMBRANES. 

Acute  Encephahtis 725 

Cerebral  Meningitis 726 


XXU  TABLE    OF    CONTENTS. 

Pachymeningitis 726 

External  Pachymeningitis 726 

Internal  Pachymeningitis 726 

Leptomeningitis 727 

Tuberculous  Meningitis 729 

Chronic  Hydrocephalus 730 

Apoplexy 731 

Cerebral  Haemorrhage 731 

Embohsm  and  Thrombosis  of  the  Cerebral  Arteries 735 

Thrombosis  of  the  Venous  Sinuses  of  the  Brain 737 

Aphasia 737 

General  Paralysis 738 

Disseminated  Sclerosis 740 

Abscess  of  the  Brain 742 

Tumors  of  the  Brain  and  its  Membranes 744 

Cerebellar  Disease 749 

DISEASES  INVOLVING  CHIEFLY  THE  SPINAL  CORD  AND  ITS 

MEMBRANES. 

Acute  Myelitis 750 

Chronic  Myelitis 750 

AT yelomalacia 754 

Acute  Anterior  Poliomyelitis 754 

Chronic  Anterior  Poliomyelitis  . 757 

Lateral  Sclerosis 757 

Amyotrophic  Lateral  Sclerosis   759 

Locomotor  Ataxia 760 

Friedreich's  Ataxia 766 

Hereditary  Cerebellar  Ataxia 767 

Bulbar  Paralysis 767 

Acute  Ascending  Paralysis 768 

Syringomyelia 770 

Morvan's  Disease 771 

Haemorrhage  into  the  Spinal  Cord 772 

Compressed  Air  Disease  773 

Compression  of  the  Spinal  Cord 778 

Tumors  of  the  Spinal  Cord  and  its  Meninges 780 

Spinal  Meningitis 782 

Spinal  Pachymeningitis 782 

Acute  Spinal  Leptomeningitis 783 

Haemorrhage  into  the  Spinal  Membranes 785 


TABLE    OF    CONTENTS.  XX]  11 

DISEASES  INVOLVING  CHIEFLY  THE  PERIPHERAL  NERVES. 

Neuritis 786 

Multiple  Peripheral  Neuritis 789 

Sciatica 792 

Diseases  of  the  Cranial  Nerves 794 

Diseases  of  the  First  Pair — The  Olfactory  Nerves 794 

Diseases  of  the  Second  Pair — The  Optic  Nerves 795 

Diseases  of  the  Third,  Fourth  and  Sixth  Pairs — The  Oculo-motor 

Nerves,  the  Trochlear  Nerves  and  the  Abducentes 798 

Diseases  of  the  Fifth  Pair — The  Trigeminal  Nerves 800 

Diseases  of  the  Seventh  Pair — The  Facial  Nerves 801 

Diseases  of  the  Eighth  Pair — The  Auditory  Nerves 804 

Diseases  of  the  Ninth  Pair — The  Glosso-pharyngeal  Nerves 806 

Diseases  of  the  Tenth  Pair — The  Pneumogastric  Nerves 807 

Diseases  of  the  Eleventh  Pair — The  Spinal  Accessory  Nerves 810 

Diseases  of  the  Twelfth  Pair — The  Hypoglossal  Nerves 813 

FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Acute  Chorea 814 

Choreiform  Affections 818 

Convulsive  Tic 819 

Impulsive  Tic 819 

Saltatory  Spasm 820 

Chronic  Chorea 820 

Epilepsy 821 

Myotonia  Congenita 827 

Paramyoclonus  Multiplex 828 

Paralysis  Agitans 829 

Eclampsia 831 

Infantile  Eclampsia 831 

Puerperal  Eclampsia 832 

Tetany 833 

Hysteria 835 

Neurasthenia 840 

The  Neurasthenia  of  the  Menopause 844 

Amok 846 

Astasia-Abasia 847 

Traumatic  Neuroses 847 

Occupation  Neuroses 848 

VASO-MOTOR  AND  TROPHIC  DISORDERS. 

Raynaud's  Disease 851 

Erythromelalgia 852 


XXIV  TABLE    OF    CONTENTS. 

Angioneurotic  CEdema 853 

Migraine , . .  . .  854 

Facial  Hemiatrophy 856 

Myasthenia  Gravis 857 

Periodical  Paralysis 858 

Adiposis  Dolorosa 859 

Acromegaly 859 

Leontiasis  Ossea 861 

Osteitis  Deformans 861 

Hypertrophic  Pulmonary  Osteoarthropathy 861 

Scleroderma 862 

Ainhum 863 

XI. 

DISEASES  OF  THE  MUSCULAR  SYSTEM. 

Myositis 865 

Infectious  Myositis 865 

Ossifying  Myositis 866 

Muscular  Dystrophies 866 

Pseudo-hypertrophic  Paralysis 866 

Juvenile  Muscular  Dystrophy 867 

Muscular  Atrophy  of  the  Landouzy-Dejerine  T}pe 868 

Muscular  Atrophy  of  the  Peroneal  Type 868 

XII. 

PARASITIC  DISEASES. 

Psorospermiasis 869 

Distomiasis 870 

Nematodes 872 

Ascariasis 872 

Anchylostomiasis 877 

Trichiniasis; 880 

Filariasis 883 

Dracontiasis 885 

Trypanosomiasis 887 

Cestodes 887 

Echinococcus  Disease 887 

Intestinal  Cestodes 887 

Parasitic  Insects 893 

Arachnidas  and  Ticks 893 

Parasitic  Flies §94 

Other  Parasitic  Insects 895 

Index 898 


INTRODUCTION. 


In  a  treatise  upon  Practical  Medicine  the  classification  of  the  various 
diseases  is  to  be  undertaken  with  circumspection,  for  the  progress  which  is 
daily  taking  place  in  the  study  of  pathologic  states  is  continually  rendering 
it  necessary  for  us  to  change  our  opinions  of  the  nature  of  morbid  condi- 
tions. Theories  which  have  been  credited  as  facts  are  frequently  being 
controverted  or  are  becoming  hypotheses  while  apparently  established  facts 
may  be  overthrown  to  give  place  to  their  successors.  As  an  instance,  pneu- 
monia and  acute  articular  rheumatism  are  now  regarded  as  infections  while 
previously  the  former  was  classed  with  diseases  of  the  lungs  and  the  latter 
with  morbid  conditions  of  the  joints.  It  is  not  at  all  improbable  that  soon 
we  shall  be  considering  certain  affections,  now  classed  as  splenic,  as  diseases 
of  the  blood  and  vice  versa,  and  other  changes  in  classification  are  quite  as 
possible.  Hence  the  difficulty  of  arranging  a  given  list  of  diseases  in  a 
manner  which  shall  not  be  subject  to  criticism. 

On  the  other  hand  it  matters  little  under  what  heading  a  disease  is  con- 
sidered, for  the  various  organs  and  bodily  systems  are  so  intimately  related 
that  an  affection  of  one  of  these  can  hardly  exist  as  a  distinct  entity.  In 
almost  every  instance  associated  morbid  processes  are  taking  place  in  other 
structures  which  have  a  definite  bearing  upon  the  primary  state. 

For  this  reason  the  present-day  tendency  toward  specialism  in  internal 
medicine  is  to  be  decried  and  a  reversion  to  the  type  of  physician  commonly 
designated  as  the  "General  Practitioner"  advocated.  It  is  such  a  medical 
man  who,  when  confronted  by  a  difficult  problem,  will  grasp  the  moment 
when  the  aid  of  the  surgeon  or  that  of  another  worker  in  special  fields  is 
necessary;  and  this  consultant  will  take  in  hand  the  work  properly  begun  by 
the  practitioner  and  carry  it  to  a  successful  conclusion  which  shall  be  quite 
as  much  a  result  of  the  skill  of  the  one  as  that  of  the  other. 

The  tendency  of  the  specialist  is  to  attribute  all  the  symptoms  of  which  he 
complains  to  some  lesion  of  the  organ  or  system  in  which  he  is  interested,  for- 
getting, perhaps,  that  other  organs  exist;  thus  the  gastrologist  loses  sight  of  the 
possibility  that  the  stomach  symptoms  of  a  patient,  to  ascertain  the  reasons 
for  which  the  resources  of  chemistry  are  exhausted,  may  be  an  evidence  of  a 
beginning  tuberculous  process  at  a  pulmonary  apex  and  are  not  due  to  some  dis- 
order of  the  gastric  motility  or  to  a  secretory  abnormality  of  the  glands  of  the 
stomach.  Likewise  the  specialist  upon  thoracic  diseases  must  not  neglect 
nor  be  unable  to  treat  intelligently  the  renal  condition  associated  with  a  given 
instance  of  pulmonary  emphysema  or  aortic  obstruction,  and  the  clinician 
who  devotes  himself  exclusively  to  the  subject  of  acute  diseases  should  recol- 
lect the  extreme  probability  of  the  occurrence  of  cardiac  involvement  when 
treating  a  patient  afflicted  with  acute  polyarthritis.      Numerous   instances 

I 


2  INTRODUCTION, 

might  be  cited  showing  the  intimate  relation  of  the  diseases  of  one  system  to 
those  of  others  but  these  will  suffice. 

In  eliciting  a  patient's  history  the  importance  of  the  consideration  of 
heredity  lies  less  in  the  possibility  of  tHe  direct  transmission  of  disease  than 
in  that  of  the  inheritance  of  a  constitution  predisposed  to  morbid  affections 
by  reason  of  its  inherited  vitiated  powers  of  resistance.  Not  only  may 
such  a  diminished  resistance  to  disease  be  handed  down  from  father  to  child 
but  there  is  a  definite  possibility  that  the  offspring  of  physically  strong  for- 
bears may  possess  an  increased  resistance  to  disease  which  may  account  for 
some  of  the  instances  of  apparent  natural  immunity  which  are  observed. 

In  considering  the  ailments  from  which  an  individual  has  previously  suf- 
fered we  must  not  lose  sight  of  the  fact  that  these  may  have  a  material  bear- 
ing upon  the  disease  which  now  brings  him  to  the  physician,  in  obtaining  the 
history  of  which  we  must  revert  to  the  first  noticed  symptom,  and  its  char- 
acter. The  associated  manifestations  must  then  be  ascertained  until  we 
are  able  to  learn  which  organ  is  chiefly  affected  and  the  others  which  are 
probably  involved  in  consequence. 

Having  elicited  the  patient's  history,  we  should  proceed  to  the  physical 
examination,  and  this  being  accomplished  we  are  finally  ready  to  make  the 
diagnosis. 

Here  it  is  a  well-recognized  fact  that,  in  every  instance,  we  must  proceed  by 
a  process  of  exclusion,  all  the  possibihties  being  ruled  out  one  by  one  until  we 
have  sifted  the  matter  to  its  bottom  and  the  true  diagnosis  is  established. 

After  diagnosis,  treatment  is  to  be  considered  and,  while  not  underrating  the 
value  of  pathological  knowledge  nor  decrying  the  importance  of  aetiology  or 
history  and  without  ignoring  the  advantage  of  expert  physical  diagnosis,  or 
minimizing  the  weight  of  trained  and  logical  reasoning  or  deprecating  the 
assumption  of  conclusions  based  on  long-continued  experience— all  of  which 
are  necessary  for  a  correct  diagnosis — we  must  insist  that  learning  and  experi- 
ence are  in  greatest  demand  in  deciding  upon  the  treatment  to  be  prescribed. 
This  is,  to  the  mind  of  the  patient,  the  most  important  consideration,  for  to 
him  history  and  diagnosis  are  merely  subsidiaries,  his  object  in  consulting  the 
physician  being  less  to  learn  the  character  of  his  ailment  than  to  obtain  relief. 

In  formulating  a  method  of  treatment  for  a  given  affection  the  various 
therapeutic  measures  at  our  disposal  must  be  considered  separately,  and,  more 
than  all,  in  prescribing  for  our  patient  we  must  not  use  the  diagnosis  as  a  figur- 
ative peg  upon  which  to  hang  a  varied  series  of  methods  of  treatment  selected 
haphazard,  but  we  should,  remembering  the  while  that  most  important  and  very 
definite  entity  the  personal  equation,  treat  the  patient  and  not  his  disease. 

With  a  view  toward  systematizing  and  correlating  our  knowledge  careful 
records  of  all  patients  should  be  kept  and  the  following  method  of  recording 
histories,  physical  examinations  and  other  data  is  suggested. 


CASE   RECORD: 


Name — Age — Occupation — Social  Condition — 
Birth-place — Place  of  Residence — Date  of 
Examination. 


History. — Hereditary  Tendencies — Notable  Habits — 
General  Surroundings — Previous  Illness  and  Ac- 
cidents— Causes,  Manner  of  Attack,  Duration  and 
Course  of  Present  Illness. 


SYMPTOMS: 


Alimentary  System.  —  Deglutition  —  Appetite  —  Sensa- 
tions during  Fasting  and  after  Eating  (Discomfort 
—  Pain —  Weight  —  Distention  — Heartburn — Nau- 
sea) —  Acidity  — Flatulence — Eructation — Pyrosis — 
Vomiting.  State  of  Bowels  {Frequency — Color  of 
Stools — Tenesmus.) 


Circulatory  System. — Subjective  Phenomena   {Pain — 
Palpitation — Faintness — Dyspncea). 


Respiratory  System. — Breathing  {Painfulness) — Cough 
— Larynx  {Pain). 


Integumentary  System. — Subjective  Phenomena — Skin 
{Dryness — Itching — Moisture ) . 


Urinary  System. — Subjective  Phenomena  {Pain  in  Loins, 
Bladder  or  Urethra) — Micturition  {Frequency). 


Reproductive  System. — Male — Abnormal  Discharges 
— Functions — Subjective  Phenomena.  Female — 
Catamenia — Pregnancies — Abnormal  Discharges — 
Subjective  Phenomena. 


Nervous  System. 

Sensory  Functions. — Sensations  {Pain — Heat — Cold — 
Formication — Numbness — Tingling — Girdle  Pain — 
Vertigo) . 

Motor  Functions.  —  Organic  Reflex  {Swallowing  — 
Breathing — Micturition — DefcBcation). 

Vasomotor  and  Trophic  Functions.-^Subjective  Phenom- 


Cerebral  and  Mental  Functions. — Subjective  Phenomena 
— Sleep. 


Locomotory  System. — Subjective  Phenomena. 

3 


Record  data  below: 


SIGNS: 


Status  Pr^sens. 
General  Facts. — Height — Weight — General  Appearance 
( Temperament — A ttitude  and  Expression) — Temper- 
ature. 


Alimentary  System. — Lips — Teeth — Gums — Tongue-- 
Fauces — {Characters,  Macroscopic  and  Microscopic, 
of  Vomited  Matters) — Character  of  Faces — {Macro- 
scopic and  Microscopic  Examinations) — Abdomen 
{Prominence  —  Retraction  —  Distention  — Flaccidity 
— Tenderness — Fluctuation — Outline  of  Normal  or 
Abnormal  Contents) — Rontgen-ray  Examination. 


Haemopoietic  System. — Lymphatic  Vessels  and  Glands 
— Ductless  Glands  {Spleen — Thyroid) — Microscop- 
ical Characters  of  Blood — Haemoglobin  Percentage — 
Specific  Gravity — Coagulation  Time — Cryosccpic 
Examination. 


Circulatory  System. — Inspection  {Form  and  Appear- 
ance of  Precordium) — Palpation  {Position  and  Char- 
acter of  Cardiac  Impulse) — Percussion  {Superficial 
and  Deep  Outline) — Auscultation  {Rhythm  and 
Quality  of  Sounds  in  Mitral,  Tricuspid,  Aortic  and 
Pulmonary  Areas,  over  General  Surface  of  Heart 
and  Main  Vessels) — Pulse  {Frequency — Rhythm — 
Character  —  Sphygmographic  Tracings)  —  Arteries, 
Veins  and  Capillaries — Rontgen-ray  Examination — 
Blood  Pressure  Estimation. 


Record  data  below: 


Respiratory  System. — Breathing  {Frequency — Rhythm 
— Type) — Sputa  {Macroscopic  and  Microscopic  Char- 
acters)— Nares  {Rhinoscopic  Examination) — -Phar- 
ynx —  Larynx — ( Voice — Tenderness — Laryngoscopic 
Examination) — Inspection  {Form  and  Action  of 
Thorax) — Mensuration  {Spirometric  Tests) — Falpa.- 
tion  {Vocal  Fremitus) — Percussion  {Anterior  and  Pos- 
terior, on  both  sides) — Auscultation  {Determination, 
during  Natural  and  Deep  Respiration,  of  the  Dura- 
tion of  the  Sounds,  their  Character,  Accompaniments, 
and  of  the  Vocal  Resonance — Tussive  Signs) — Ront- 
gen-ray Examination. 


SIGNS  (Continued) : 


Integumentary  System. — O besity  —  Emaciation- 
(Edema — Emphysema  —  Eruptions  {Distribution- 
Elements  of  Skin  Involved — Type — Cause). 


Urinary  System. — Urine —  Quantity —  Color — Specific 
Gravity — Chemical  Reactions  {Acidity — Alkalinity 
—  A  Ibumin  —  Sugar  —  Bile — Indican  —  A  mount  of 
Urea  and  Uric  Acid) — Sediment  {Macroscopic  and 
Microscopic  Characters) — Cryoscopic  Examination — 
Rontgen-ray  Examination. 


Reproductive  System. — Male — Testicle  —  Epididymis 
— Prostate — Urethra  {Endoscopic  Examination) — 
Bladder  {Cystoscopic  Examination  and  Result  of 
Ureteral  Catheterization) — Abnormal  Discharges. 
Female — Ovaries — Tubes — Pelvic  Cavity — Uterus 
— Vagina  {Examination  with  Speculum) — Urethra 
{Endoscopic  Examination) — Bladder  {Cystoscopic 
Examination  and  Result  of  Ureteral  Catheterization) 
— Abnormal  Discharges. 


Nervous  System. 

Sensory  Functions. — Sensibility  to  Touch  {.tEsthesio- 
metric  Examination)  —  Heat  —  Tickling  —  Pain  — 
Muscular  Sense — Sight  {Ophthalmoscopic  Examin- 
ation)— Hearing  {Otoscopic  and  Horological  Exam- 
ination)— Taste — Smell. 

Motor  Functions. — Skin  Reflex — Tendon  Reflex — Vol- 
untary {Systematic  Examination  of  Muscles) — Co- 
ordinating— Electric  Irritability  {Faradic,  Galvanic). 

Vasomotor  and  Trophic  Functions. — {Congestion — Pallor 
— QLdema  —  Inflammation  —  Sloughing — Wasting — 
Perspiration.) 

Cerebral  and  Mental  Functions. — Intelligence  {Halluci- 
nations —  Illusions —  Delusions — Delirium — Torpor 
— Coma  —  Coma-  Vigil)  —  Attention —  Memory  — 
Emotion  —  Speech — {Comprehension  of  Language, 
heard,  seen — Utterance  of  Language,  spoken,  written) 
— Rbntgen-ray  Examination. 


Locomotory  System. — Bones — Joints — {Pain — Swelling 
— Effusion — Mobility — Rontgen-ray  Examination) 
— Muscles  {Rigidity — Flaccidity — Cramp — Twitch- 
ing, general  or  fibrillary — Hypertrophy — Atrophy — 
Dynamometric  Examination) . 

5 


Record  data  below: 


DIAGNOSIS: 


PROGNOSIS: 


TREATMENT: 

Medicinal  t 


Physical  t  (Electricity,  massage,  hydrotherapy,  etc.). 


Dietetic: 


Hygienic  I 


General  Directions: 


Subsequent  History: 


PRACTICAL  MEDICINE. 


CHAPTER  I. 

THE  INFECTIOUS  DISEASES. 

ENTERIC  FEVER. 

Synonyms.  Typhoid  Fever;  Typhus  AbdominaHs;  Gastro-enteric  Fever; 
Nervous  Fever. 

Definition.  Enteric  fever  is  an  acute  infectious  febrile  disease  character- 
ized by  inflammation  and  ulceration  of  the  Peyer's  patches  or  lymph  follicles 
of  the  intestine,  by  swelling  and  inflammation  of  the  mesenteric  glands, 
enlargement  of  the  spleen  and  a  petechial  eruption. 

.Etiology.  The  specific  cause  of  enteric  fever  is  the  bacillus  typhosus  of 
Eberth-Gaffky.  This  bacillus  is  to  be  found  in  the  stools,  the  urine,  the  blood, 
the  lymph  patches  of  the  intestines,  the  lymph  glands,  the  spleen,  the  skin 
eruption  and  in  the  marrow  and  various  organs.  It  usually  enters  the  organ- 
ism in  infected  water  or  milk  or  upon  contaminated  food,  such  as  oysters  which 
have  been  bedded  near  sewer  exits,  or  green  vegetables  which  have  been 
fertilized  by  means  of  sewage.  It  is  contended  by  some  that  the  bacillus  is  air 
borne  and  may  enter  the  respiratory  system  and  thus  reach  the  blood.  Sew- 
age to  be  contaminated  by  the  bacillus  must  have  received  either  directly 
or  indirectly  the  discharges  from  a  patient  suffering  from   the  disease. 

Enteric  fever  is  more  common  in  the  young  adult  than  in  childhood,  middle 
or  old  age  and  seems  to  attack  the  vigorous  and  healthy  as  often  as  the  weak 
and  enfeebled.  Men  seem  more  susceptible  than  women,  but  this  is  probably 
because  they  are  more  liable  to  exposure.  The  disease  is  most  frequently 
seen  in  the  late  summer  and  early  autumn  and  may  occur  in  almost  any  chmate. 
It  is  commonly  endemic  but  epidemics  occur  at  intervals.  One  who  has  once 
had  the  disease  seldom  suffers  from  a  second  attack. 

Pathology.  The  most  characteristic  lesion  of  enteric  fever  is  the  inflam- 
mation of  the  solitary  and  agminated  glands  of  the  small  intestine.  These 
glands  are  first  congested  and  swollen,  later  they  disintegrate  and  necrose, 
and  the  formation  of  ulcers  takes  place.  When  a  solitary  gland  is  involved 
the  ulcer  is  small  and  round;  in  the  agminated  glands  it  is  oval  with  its  long 

7 


S  THE    INFECTIOUS    DISEASES. 

diameter  parallel  to  the  long  axis  of  the  intestine.  The  borders  of  the  ulcers 
are  raised;  their  bases,  which  may  consist  of  the  submucosa,  the  muscular 
coat  of  the  bowel  or  of  peritonaeum,  are  necrotic.  The  ulcer  may  erode  all  the 
coats  of  the  gut  and  the  peritonaeum,  and  perforation  may  take  place,  local  or 
general  peritonitis  resulting.  More  usually,  fortunately,  the  ulcer  gradually 
heals  but  the  return  of  the  glandular  tissue  to  normal  does  not  take  place. 
In  a  number  of  the  patients  the  large  intestine  is  involved  as  also  may  be  the 
appendix.     In  either  of  these  situations  perforation  may  occur. 

Inflammation  of  the  mesenteric  lymphatic  glands  and  of  the  spleen  is 
likely  to  occur,  resulting  in  increase  in  the  size  of  these  structures.  The  spleen 
is  usually  palpable  and  may  be  enlarged  to  two  or  three  times  its  normal  size. 
Abscesses  have  been  reported. 

Thromboses  of  the  veins  may  occur,  especially  of  those  of  the  leg.  Arterial 
thrombosis  is  rare.  The  pericardium,  myocardium  or  endocardium  may  be 
the  seat  of  inflammation  due  to  the  infection. 

Respiratory  lesions,  such  as  inflammations  of  the  larynx,  bronchi,  or  pleura, 
are  not  infrequent.     Empyema  is  rare. 

The  liver  is  the  seat  of  an  acute  degeneration,  with  granular,  and  at  times 
fatty,  changes  in  its  cells.  Abscess  may  occur.  The  bacillus  has  been  found 
in  the  gall-bladder  and  a  typhoid  cholecystitis  may  occur. 

The  kidneys  also  undergo  an  acute  degeneration  in  their  parenchyma; 
rarely  there  may  be  an  acute  nephritis.  Abscesses  of  the  kidney  are  rare. 
Pyelitis   and   cystitis   may  complicate   the   disease. 

Lesions  in  the  nervous  system  are  infrequent,  but  meningitis  has  been 
met  as  also  has  cerebral  abscess. 

Abscesses  in  various  parts  of  the  body,  notably  under  the  periosteum  and 
in  the  parotid  gland,  are  not  uncommon. 

Course  and  Symptoms.  The  incubation  period  is  usually  about  two 
weeks,  and  may  be  accompanied  by  lassitude  and  lack  of  appetite.  Occa- 
sionally the  patient  may  continue  up  and  about  after  the  onset  of  the  disease 
(walking  typhoid).  The  inception  of  enteric  fever  is  gradual,  with  headache, 
general  bodily  pains,  nausea  and  vomiting  and  a  rise  of  temperature. 
Chilly  feelings  may  occur,  but  a  distinct  chill  is  rare.  There  may  be  nose- 
bleed and  slight  bronchitis,  evidenced  by  cough.  In  children  the  onset  is 
more  usually  acute.  The  bowels  may  be  loose  or  constipated.  There  may  be 
abdominal  tenderness  and  distention.  About  the  eighth  day  the  eruption, 
consisting  of  small  isolated,  rose-colored,  slightly  elevated  round  or  oval  spots 
of  about  2  to  4  millimeters  in  diameter,  appears.  These  disappear  on  pres- 
sure but  reappear  when  the  pressure  is  removed.  They  are  seen  earliest 
upon  the  back,  and  slightly  later  upon  the  chest  and  abdomen.  They 
may  be  found  upon  the  arms  and  thighs,  but  very  rarely  upon  the  forearms 
and  legs.     They  appear  in  successive  crops,  each  crop  lasting  2  to  4  days, 


ENTERIC    FEVER.  9 

while  the  eruptive  period  lasts  from  2  to  21  days.  Relapses  show  a  fresh 
eruption  and  the  spots  may  appear  during  convalescence. 

The  course  of  the  disease  usually  lasts  about  four  weeks  and  to  each  week 
belong  certain  symptoms. 

The  typical  temperature  of  enteric  fever  is  as  follows:  After  the  chill 
at  onset  the  temperature  rises  and  during  the  week  following  it  is  high  at 
night  and  lower  in  the  morning,  but  day  by  day  the  differences  between  these 
temperatures  become  less.  During  the  second  week  the  temperature  is 
continuously  high  and  there  is  little  difference  between  that  of  the  morning 


Fig.  I. — Clinical  chart  of  enteric  fever  of  four  weeks'  duration  without  complications 
and  showing  the  temperature  as  uninfluenced  by  baths  or  other  treatment. 


and  that  of  the  evening.  In  the  third  week  the  morning  temperature  becomes 
lower  while  that  of  the  evening  remains  as  high  as  dtiring  the  second  week. 
The  typical  fourth  week  temperature  is  one  in  which  the  morning  temperature 
falls  gradually  lower  and  that  of  the  evening  does  likewise,  dropping  to  a 
lower  level  each  day  until  both  it  and  the  morning  temperature  reach 
normal. 

Complications  may  alter  the  course  of  the  temperature.  Intestinal  haem- 
orrhages are  usually  followed  by  a  rapid  and  distinct  fall.  The  height  of  the 
temperature  is  commonly  in  direct  proportion  to  the  severity  of  the  infection 
and  usually  in  fatal  instances,  unless  death  results  from  one  of  the  complications 


lO  THE    INFECTIOUS    DISEASES. 

above  mentioned,  the  temperatiire  remains  high  until  death  takes  place; 
infrequently,  however,  death  may  supervene  v^^ithout  the  temperature  ever 
having  reached  a  very  high  level. 

The  pulse  usually  bears  a  direct  relation  to  the  temperature  curve.  In  the 
first  week  it  is  fvill,  tense  and  strong  and  from  go  to  loo  per  minute;  during 
the  second  week,  especially  in  severe  infections,  it  is  likely  to  become  rapid, 
feeble  and  possibly  dicrotic. 

Various  departmres  from  the  typical  temperature  are  not  rare.  When 
the  disease  begins  with  a  chill  the  temperature  may  rise  at  once  as  high  as 
103°  F.  or  104°  F.  (39.5°-4o°  C).  Not  infrequently  does  defervescence  take 
place  at  the  end  of  the  second  week  and  the  temperature  fall  to  normal 
within  24  hours.  A  temperature  higher  in  the  morning  and  lower  in  the 
evening  may  occur  but  has  no  especial  significance.  Sudden  falls  in  tem- 
perature usually  indicate  an  intestinal  haemorrhage  or  perforation.  Hyper- 
pyrexia is  rare  but  may  be  observed  just  before  death.  Chills  may  occur, 
as  stated,  at  the  onset  of  the  disease;  at  intervals  during  its  progress;  with  the 
incidence  of  complications;  after  the  use  of  antipyretic  drugs  or  baths;  or 
during  convalescence  with  no  assignable  cause. 

The  chills  may  be  accompanied  by  sweating,  but  profuse  diaphoresis  is 
rare,  though  at  times  the  abdomen  and  chest  may  be  moist,  especially  during 
the  reaction  from  a  bath. 

Rises  of  temperature  after  defervescence  (recrudescences)  may  take  place 
even  after  there  has  been  no  febrile  movement  for  several  days.  These 
may  continue  for  a  number  of  days  and  then  cease.  Accompanying  them 
there  is  no  constitutional  distxirbance,  but  they  call  for  increased  vigilance 
on  the  part  of  the  physician.  They  are  usually  the  result  of  improper  feeding, 
constipation  or  mental  excitement. 

Certain  patients  in  whom  convalescence  has  apparently  become  established 
continue  to  show  an  evening  rise  of  temperature  of  one  or  two  degrees  (F.). 
This  may  be  due  to  starvation  but  should  cause  the  physician  to  search  for 
complications,  particularly  abscesses.  In  excessively  nervous  patients  such 
an  evening  rise  is  frequent,  but  if  no  other  symptoms  are  manifest  it  may 
be  disregarded  and  it  often  disappears  if  the  patient  is  allowed  to  sit  up,  is 
given  small  amounts  of  solid  food  and  the  use  of  the  thermometer  is  dis- 
continued. 

Relapses  are  due  to  a  fresh  infection  with  the  bacillus  typhosus  and  last 
varying  periods  of  time;  as  a  rule  they  are  shorter  in  coiu-se  than  the  original 
attack.  The  temperature  rises  and  declines  gradually  and  is  accompanied 
by  a  return  of  the  symptoms. 

Afebrile  enteric  fever  has  been  described  by  certain  observers  but  is  appar- 
ently of  rare  occurrence. 

The  facial  appearance  of  enteric  fever  has  been  described  as  typical.  Early 


ENTERIC    FEVER.  II 

in  the  disease  the  face  is  flushed  and  the  eyes  are  bright;  by  the  beginning 
of  the  second  week  the  expression  becomes  apathetic  and  at  the  height  of  the 
disease  it  is  dull  and  listless — the  typhoid  facies.  The  lips  and  cheeks  may 
retain  a  good  color  throughout  the  disease. 

The  typhoid  tongue  is  at  first  moist  with  a  white  coat  down  its  center.  Its 
edges  and  tip  are  red.  In  mild  infections  the  tongue  continues  moist  but  in 
severe  types  of  the  disease  it  becomes  dry,  brown,  cracked  and  glazed  in  the 
later  weeks.  Sordes  may  make  its  appearance.  As  convalescence  progresses 
the  tongue  gradually  assumes  its  normal  condition. 

The  spleen  is  regularly  enlarged,  soft  and  may  usually  be  palpated  with- 
out difi&culty. 

Unusual  Modes  of  Onset,  a.  Ambulatory  or  walking  enteric  fever:  In 
this  type  of  the  disease  the  patient  remains  up  and  attempts  to  go  about  his  usual 
occupation.  He  realizes  that  he  is  not  in  perfect  health  but  feels  hardly  ill 
enough  to  go  to  bed.  When  he  is  first  seen  by  the  physician  he  may  have  a 
high  fever  and  a  well-developed  rash.  These  infections  often  prove  severe  be- 
cause of  lack  of  proper  treatment  in  the  early  stages. 

b.  With  marked  gastro-intestinal  symptoms:  The  nausea  may  be  severe 
and  the  vomiting  almost  continuous  and  very  difficult  to  control.  Profuse 
diarrhoea  may  be  present. 

c.  The  usual  cough  accompanying  the  onset  may  be  much  accentuated 
and  the  chill  and  pain  in  the  side  of  such  character  as  to  suggest  pneumonia. 

d.  With  symptoms  referable  to  the  kidneys:  Rarely  we  may  observe 
an  onset  distinguished  by  bloody  urine  containing  albumin  and  casts. 

e.  With  pronounced  nervous  symptoms:  Agonizing  and  obstinate  headache 
or  facial  neuralgia  may  be  initial  symptoms.  In  certain  instances  when  the 
patient  has  continued  about  during  the  early  weeks  delirium  may  be  the  first 
marked  symptom.  Rarely  the  disease  may  begin  with  muscular  twitchings 
or  convulsions,  stiffness  of  the  neck  and  photophobia.  Drowsiness,  apathy 
and  stupor  may  exist  for  some  days  before  other  and  more  typical  symptoms 
develop.  Very  infrequently  is  mania  the  first  symptom.  In  alcoholic  patients 
the  various  nervous  manifestations  are  especially  marked. 

f.  Intestinal  haemorrhage  or  perforation  may  rarely  occxu-  as  symptoms  of 
onset. 

Each  week  of  the  course  of  enteric  fever  in  a  typical  instance  is  marked  by 
a  special  set  of  symptoms.  During  the  incubation  period — varying  from 
lo  to  21  days,  usually  about  two  weeks — the  patient  suffers  from  indefinite 
malaise,  nausea,  headache  and  general  soreness. 

First  Week.  The  invasion  of  the  disease  is  marked  by  chilly  feelings, 
more  rarely  by  a  distinct  chill,  severe  frontal  headache  and  pains  in  back 
and  limbs;  the  tongue  is  coated  down  its  center,  its  edges  and  tip  are  redder 
and  the  papillae  more  prominent  than  normal.     There  often  is  spontaneous 


12  THE    INFECTIOUS    DISEASES. 

nose-bleed  and  there  is  likely  to  be  cough  due  to  slight  laryngitis  or  bronchitis. 
The  eyes  are  suffused.  The  patient  is  thirsty  and  often  conscious  that  his 
temperature  is  elevated.  He  complains  of  weariness,  insomnia  and  nausea 
which  is  often  accompanied  by  vomiting.  Constipation  is  the  rule  but 
diarrhoea  may  be  present.  There  may  be  sore  throat  with  discomfort  on 
deglutition.  During  this  stage  of  the  infection  the  patient  may  continue  up 
and  about,  but  usually  he  finds  that  he  is  more  comfortable  in  bed.  The 
course  of  temperature  has  been  described;  by  the  fifth  or  sixth  day  it  reaches 
an  evening  elevation  of  103°  to  103.5°  ^-  (39-5°  to  39-8°  C).  The  pulse 
is  rapid,  strong  and  tense,  90  to  100  per  minute.  Very  rarely  is  it  dicrotic. 
By  the  end  of  the  week  the  typical  enteric  facies  is  evident.  A  few  spots 
may  be  seen  and  the  spleen  may  be  palpable. 

Second  Week.  As  the  second  week  progresses  all  the  symptoms  become 
more  marked  with  the  exception  of  the  headache  and  other  pains  and  the 
nausea  and  vomiting;  these  usually  cease.  The  temperature  continues  high 
(io3°-io4°  F. — 39.5°  to  40°  C.)  with  slight  morning  remissions.  The  pulse 
becomes  softer,  feebler  and  more  rapid  (100-120).  Bodily  weakness  is  pro- 
nounced. The  tongue  is  dry,  brown  and  tremulous;  there  is  likely  to  be 
diarrhoea,  3  to  5  thin,  pale,  yellowish-brown  movements  a  day  (pea-soup 
stools).  Mild  delirium  may  appear  late  in  this  week;  at  first  it  is  present 
only  at  night,  later  it  lasts  through  the  day  as  well  and  the  patient  shows 
other  effects  of  the  toxin  of  the  disease  upon  the  nervous  system,  such  as 
photophobia,  slight  deafness  and  muscular  twitchings.  If  there  is  no  delir- 
ium the  patient  lies  in  a  lethargic  condition,  takes  no  interest  in  his  surround- 
ings and  makes  no  requests. 

Third  Week.  The  symptoms  of  the  second  week  continue  and  become 
more  pronoimced.  The  temperature  continues  high,  but  as  the  week  nears 
its  close,  the  morning  temperature  is  likely  to  fall  to  a  lower  level  (ioi°-io2°  F., 
38.4°-38.8°  C).  The  pulse  may  become  very  rapid  and  weak  and  dicrotism 
may  be  manifest.  The  tongue  becomes  more  dry  and .  cracked  and  the 
patient  may  be  unable  to  protrude  it.  Bed  sores  may  appear  and  retention 
of  urine  and  incontinence  of  faeces  may  occiu*.  The  symptoms  of  cerebral 
poisoning  become  more  marked,  the  muscular  twitchings  {suhsultus  tendi- 
num)  are  more  noticeable  and  the  patient  may  pick  at  the  bed  coverings  or 
grasp  at  imaginary  objects.  Intestinal  haemorrhage  may  be  evidenced  by 
blood-tinged  stools  or  blood  in  considerable  quantity  may  flow  from  the 
rectum,  leaving  the  patient  in  collapse  with  a  sudden  fall  in  temperature, 
imperceptible  pulse  and  other  symptoms  of  extreme  weakness.  Pulmonary 
congestion  or  pneumonia  may  complicate  the  disease  during  this  week. 
Meteorism  is  not  rare.     The  patient  may  die  or  continue  to  the 

Fourth  Week.  Now  the  morning  temperature  falls  still  lower  and  the 
evening  rise  gradually  becomes  less  until  the  former  reaches  normal  and  the 


ENTERIC    FEVER. 


13 


latter  ioi°-io2°  F.  (38.4°-38.8°  C.)-  As  the  temperature  diminishes  the 
other  symptoms  gradually  ameliorate,  the  tongue  loses  its  dry,  cracked  appear- 
ance and  becomes  moist,  the  pulse  is  stronger,  the  nervous  manifestations 
disappear,  and  the  appetite  becomes  more  vigorous. 

Fifth  Week.  The  patient  may  immediately  proceed  to  complete  recovery, 
the  febrile  movement  may  last  two  or  three  weeks  longer,  or  after  a  normal 
temperature  lasting  several  days,  a  relapse  may  take  place. 

Convalescence  is  slow.  The  patient  is  extremely  weak  although  he  may 
feel  well  and  be  very  hungry.  He  is  able  to  sit  up  but  for  a  few  moments 
at  a  time  and  walking  is  quite  impossible.  Relapses  may  be  brought  on 
by  errors  in  diet  or  by  over-exertion.  The  patient  often  loses  his  hair  for  a 
time  and  it  usually  is  a  number  of  months  before  full  strength  is  recovered. 
Dysmenorrhoea  is  a  common  sequel  in  women. 

Menstruation  usually  takes  place  as  in  health  during  the  first  or  second 
week,  but  later  and  in  convalescence  it  may  be  absent.  Pregnant  women, 
though  they  seldom  contract  the  disease,  often  abort  during  its  course. 

Complications.  Thrombosis  of  the  veins,  more  particularly  of  the  left 
femoral — although  it  may  occur  in  both  femoral  veins — takes  place  in  about 
I  percent,  of  all  cases.  Recovery  is  the  rule  unless  emboli  dislodged  from 
the  clot  find  their  way  to  the  heart,  in  which  case  sudden  death  takes  place. 
There  is  usually  phlebitis  of  greater  or  less  extent  as  well  as  thrombosis,  and 
arterial  thrombosis  is  a  possible  occurrence.  The  bacillus  typhosus  has  been 
found  in  the  thrombi. 

Hemorrhage  from  the  bowel  is  a  serious  complication  and  is  the  result 
of  the  erosion  of  a  vessel  wall  by  the  ulcerative  process.  It  is  said  to  occur 
in  about  5  percent,  of  the  cases.  It  is  by  no  means  necessarily  fatal,  recovery 
having  taken  place  after  the  loss  of  large  quantities  of  blood  per  rectum.  Such 
a  haemorrhage  is  evidenced  by  rapid  drop  of  temperature,  pallor,  coldness  of 
the  extremities  and  other  symptoms  of  collapse. 

Perforation  is  also  marked  by  a  sudden  fall  in  temperatyre  as  well  as  by 
severe  abdominal  pain  and  symptoms  of  collapse.  The  pain  is  rarely  localized 
but  is  usually  general  over  the  whole  abdomen.  This  is  a  markedly  fatal 
complication,  the  only  chance  for  recovery  being  immediate  surgical  inter- 
ference; otherwise  general  peritonitis  results. 

Peritonitis  without  perforation  may  occur  by  extension  of  the  inflammation 
within  the  intestine  to  the  peritonaeum  surrounding  it.  It  is  a  grave,  though 
not  necessarily  fatal  complication. 

Parotitis  followed  by  suppuration  is  rare.  The  infection  reaches  the  gland 
by  means  of  Stensen's  duct. 

Cancrum  oris  may  complicate  or  follow  the  disease  in  children.  Gangrene 
of  other  parts  may  occur  but  is  rare. 

Pneumonia  due  either  to  the  bacillus  typhosus  or  the  pneumococcus  may 


14  THE    INFECTIOUS    DISEASES, 

occur  either  early  or  late  in  the  disease.  In  the  later  weeks  hypostatic  pneu- 
monia may  complicate  the  course  of  the  infection. 

Suppuration  in  various  parts  of  the  body  as  a  result  of  enteric  infection  is 
not  rare.  The  most  common  situations  are  the  middle  ear,  the  periosteum, 
the  urinary  bladder  and  the  gall-bladder.  Furunculosis  is  not  uncommon. 
The  pus  of  these  lesions  usually  contains  the  bacillus  typhosus. 

Osteitis  and  perichondritis  are  common.     These  may  result  in  necrosis. 

Typhoid  spine  is  a  rare  complication  and  is  the  result,  in  all  probability, 
of  an  inflammation  in  and  around  the  bodies  of  the  vertebrae. 

Cholelithiasis  as  a  sequel  of  typhoid  fever  is  well-recognized.  It  is  prob- 
ably the  Jesuit  of  changes  in  the  gall-bladder  or  in  the  biliary  secretion  due 
to  the  presence  of  the  bacillus  typhosus  and  which  facilitate  the  formation 
of  calculi. 

Neuritis  is  fairly  common  and  may  occur  during  the  course  of  the  disease 
or  in  convalescence.  Its  onset  is  marked  by  great  tenderness  along  the 
course  of  the  affected  nerves.  There  may  be  a  slight  degree  of  paralysis, 
usually  involving  the  extensor  muscles  of  the  limbs  and  evidenced  by  wrist 
and  foot-drop. 

Endocarditis,  pericarditis  and  pleuritis  are  infrequent  complications. 

Bed  sores  may  develop  in  severe  cases  and  in  those  not  well  cared  for. 
They  are  a  dangerous  and  unnecessary  complication. 

The  Blood.  During  the  course  of  enteric  fever  the  red  blood  cells  and 
haemoglobin  are  diminished;  during  the  early  weeks  the  diminution  is  gradual. 
As  the  temperature  becomes  normal  this  diminution  takes  place  more  rapidly. 
The  red  corpuscles  are  usually  fewest  when  convalescence  begins  and  as 
recovery  progresses  they  increase  in  number.  The  haemoglobin  percentage 
is  usually  lower  than  the  number  of  red  cells  would  lead  us  to  expect  and 
it  increases  more  slowly  than  does  the  number  of  erythrocytes. 

The  leucocytes  early  in  the  disease  show  a  diminution,  in  a  very  large  per- 
centage of  patients  they  are  less  than  7,000  per  cu.mm.  Non-typhoid  com- 
plications do  not  seem  to  diminish  this  tendency  to  hypoleucocytosis.  Haem- 
orrhage and  perforation  are  followed  by  an  increase  in  the  white  cells.  It 
may  be  considered  that  a  leucocyte  count  above  12,000  at  the  beginning  of 
an  illness  is  strong  evidence  against  enteric  fever.  The  leucocytes  diminish  as 
the  disease  progresses,  reaching  the  minimum  at  the  termination  of  the  febrile 
movement,  and,  as  convalescence  is  established,  beginning  to  increase  again. 

Cold  baths  seem  to  temporarily  increase  the  number  of  leucocytes  but  this 
is  believed  to  be  due  to  a  tendency  upon  their  part  to  seek  the  surface  capil- 
laries rather  than  a  true  leucocytosis.  A  sudden  increase  in  the  number 
of  leucocytes  is  considered  to  be  a  warning  of  threatened  peritonitis  or  per- 
foration. In  complicating  suppurative  conditions  there  is,  as  one  would 
expect,  a  leucocytosis. 


ENTERIC    FEVER.  1 5 

During  the  disease  the  blood  contains  the  bacillus  typhosus  and  this  organ- 
ism may  be  cultivated  from  it,  which  fact  may  be  utilized  in  diagnosis. 

The  Widal  reaction  is  based  upon  the  fact  that  the  blood-serum  of  persons 
suffering  from  enteric  fever  possesses  the  property  of  arresting  the  motion  of 
and  agglutinating  the  causative  germ.  This  reaction  exists  in  over  95  percent.* 
of  cases  and  is  a  valuable  diagnostic  aid.  It  is  seldom  observed  before  the 
patient  has  been  ill  enough  to  have  been  in  bed  for  from  5  to  7  days.  At 
times  the  reaction  is  not  present  until  after  the  establishment  of  convalescence. 
If  it  is  not  obtained  upon  the  first  attempt,  others  should  be  made  at  intervals. 
The  reaction  may  disappear  after  the  cessation  of  the  pyrexia  or  it  may  persist 
for  months  or  even  years. 

The  urine  in  enteric  fever  is  dark  in  color,  high  in  acidity  and  specific 
gravity,  and  may  contain  albumin  and  casts.  The  bacillus  typhosus,  in  a  large 
percentage  of  patients,  is  present  in  the  urine,  appearing  therein  usually  in 
the  second  or  third  week  and  persisting  into  the  period  of  convalescence. 
At  times  these  organisms  may  continue  to  be  present  for  many  months, 
probably  being  propagated  in  the  bladder.  Their  presence  is  of  no  impor- 
tance in  prognosis. 

Ehrlich's  diazo-reaction  is  so  often  present  in  the  urine  of  enteric  fever 
that  its  aid  in  diagnosis  should  always  be  invoked.  It  is  not  pathognomonic, 
since  it  may  occur  in  other  conditions.  It  is  usually  present  early  in  the  in- 
fection.f 

Prophylaxis.  The  prevention  of  enteric  fever  resolves  itself  primarily  into 
the  destruction  of  the  specific  bacillus,  or  failing  this,  the  prevention  of  its 
entrance  into  the  human  body.  All  excreta,  faeces,  urine,  pus  from  abscesses, 
etc.,  as  well  as  all  bed  clothing,  bath  waters  and  all  utensils  which  have  in 
any  way  come  into  contact  with  the  patient  should  be  properly  disinfected 
or  disposed  of  in  other  ways. 

The  faeces  should  be  passed  into  glass  or  porcelain  vessels  and  must  be 
thoroughly  macerated  and  allowed  to  stand  for  at  least  one  hour  mixed  with 
a  freshly  prepared  disinfecting  solution  such  as  calcium  chloride,  four  ounces, 
water,  one  gallon.  The  urine  should  stand  for  ten  minutes  mixed  with  one- 
tenth  of  its  volume  of  mercury  bichloride  i  to  i  ,000.  Sputum  should  be  expec- 
torated into  vessels  containing  phenol  i  to  10,  or  the  lime  solution  given  above. 
Bath  water  and  remnants  of  food  should  be  disinfected  with  lime  or  phenol 
solution.  Bed  linen  and  clothing,  before  being  sent  to  the  laundry,  should 
be  immersed  in  a  solution  of  phenol  3  to  100,  or  boiled  in  soapsuds  to  which 
washing  soda  has  been  added.     Pus  dressings  and  the  like  should  be  burned. 

The  sick-room  should  be  disinfected  in  the  manner  customary  after  the 
infectious  diseases. 

*  Simon. 

t  For  technique  of  the  Widal  and  Ehrlich  reactions  see  works  on  laboratory  diagnosis. 


1 6  THE    INFECTIOUS    DISEASES. 

Since  the  bacillus  typhosus  usually  enters  the  system  by  way  of  the  mouth 
too  great  care  cannot  be  taken  to  be  certain  that  all  ingested  substances  are 
above  suspicion. 

The  specific  bacillus  of  enteric  fever  being  excreted  in  the  urine  naturally 
necessitates  the  thorough  disinfection  of  this  fluid  as  is  suggested  in  a  previous 
paragraph.  An  additional  safeguard  in  this  connection  is  the  administration 
of  hexamethylenamine  (urotropin)  in  doses  of  7^  grains  (0.5)  three  times  daily. 
This  drug  is  believed  to  render  the  urine  sterile  since  it  is  excreted  in  this 
fluid  as  formaldehyde.  This  means  of  safeguarding  the  pubUc  health  should 
never  be  neglected;  rendering  the  urine  free  from  infective  properties  is  also 
important  from  the  standpoint  of  the  patient  and  is  not  to  be  neglected  in  the 
treatment  of  the  disease.  The  administration  of  the  drug  should  be  begun 
not  later  than  the  third  week  of  the  affection  and  should  be  continued  for 
several  weeks  into  convalescence. 

Anti-enteric  inoculation  has  been  attempted  by  various  experimenters 
and  the  result  of  their  observations  may  be  summed  up  in  the  statement 
that  the  measure  is  one  which,  in  properly  selected  cases,  is  fraught  with 
little  or  no  danger,  and,  so  far  as  we  are  able  to  judge,  one  which  should  not 
be  neglected  when  there  is  probability  of  exposure  to  the  infection  of  the 
disease. 

Treatment.  In  the  treatment  of  typhoid  fever  it  is  of  the  greatest  impor- 
tance that  all  patients  should  be  strictly  confined  to  bed  during  the  febrile 
stage  of  the  disease  and  well  beyond  this  into  convalescence.  In  a  private 
house  the  bed  should,  when  possible,  be  in  a  large,  well-ventilated  room 
from  which  all  hangings  and  superfluous  furniture  have  been  removed.  The 
temperature  should  not  be  above  60°  F.  (15.5°  C.)  and  in  favorable  weather 
the  windows  should  be  open.  Too  bright  light  and  too  much  darkness  are 
to  be  avoided.  The  bed  should  not  be  too  heavily  covered,  and  the  bed  linen 
must  be  kept  perfectly  smooth  and  frequently  changed.  In  severe  infections 
the  air  or  water  bed  may  be  necessary.  Early  in  the  disease  dorsal  decubitus 
is  the  best  position,  but  later  the  patient  may  be  encouraged  to  change  his 
attitude  lest  there  be  any  tendency  to  pulmonary  hypostasis.  The  mouth, 
teeth  and  tongue  should  be  frequently  cleansed.  Studious  attention  should 
be  given  to  the  proper  cleanliness  of  the  body  and  all  points  at  which  bed 
sores  are  likely  to  develop  must  receive  special  care.  The  bowels  and  bladder 
should  be  evacuated  only  when  the  patient  is  lying  on  his  back. 

Since  febrile  diseases  actively  consume  the  body  proteid  this  loss  must 
be  supplied  in  so  far  as  possible,  by  nourishing  food.  The  fact  that  the  diges- 
tive fluids  are  altered  makes  this  a  complicated  problem  and  the  pathological 
changes  in  the  digestive  tract  add  to  the  difficulty.  During  the  febrile  move- 
ment of  typhoid  fever,  and  usually  for  some  time  thereafter,  fluid  diet  should  be 
strictly  enforced.     If  the  patient  has  a  lack  of  appetite  the  physician  may 


ENTERIC    TEVER.  1 7 

combat  this  by  careful  variation  of  the  diet  in  accordance  with  the  tastes  of 
the  patient.  Cold  drinks  need  not  be  restricted,  water,  plain  or  with  fruit 
juices,  natural  mineral  waters  containing  not  too  much  carbon  dioxide,  and 
cold  tea  may  be  allowed. 

Milk  is  the  most  perfect  food,  though  some  patients  object  to  it  and  others 
do  not  bear  it  well  for  any  length  of  time.  In  such  instances  it  may  be  diluted 
with  plain  water,  mineral  water  or  Ume  water,  or  to  it  may  be  added  tapioca 
or  arrowroot.  If  milk  appears  undigested  in  the  stools  too  much  has  been 
administered;  the  quantity  should  be  lessened  and  broths  should  be  given. 
Buttermilk,  peptonized  milk,  thin  barley  gruel  and  albumin  water  are  allowable. 
Simple  ice-cream  made  of  milk  with  the  addition  of  a  little  sugar  and  vanilla 
may  prove  acceptable.  Often  the  artificial  infant  foods,  meat  broths  and 
bouillon  are  useful  and  well  borne. 

One  week  after  the  cessation  of  the  febrile  stage  the  patient  may  be  given 
solid  food;  at  first  toast,  a  soft  egg,  scraped  beef,  to  be  followed  a  few  days 
later  by  roast  fowl  and  puree  soups.  At  the  end  of  the  second  afebrile  week, 
steak,  chops  and  green  vegetables  may  be  added.  Some  patients,  after  the 
acuity  of  the  disease  has  subsided,  continue  to  have  an  evening  rise  of  tem- 
perature of  two  or  three  degrees  (F.);  to  such,  if  the  nourishment  is  impaired 
and  the  need  of  food  is  manifest,  we  may  allow  a  gradual  return  to  solid  diet. 
Usually  the  temperature  promptly  subsides  and  no  harm  is  done. 

The  specific  treatment  of  typhoid  fever  by  means  of  an  antitoxin  has  as  yet 
given  no  very  favorable  results.  The  difficulty  in  the  preparation  of  an 
antityphoid  serum  is  that  typhoid  fever,  unlike  diphtheria,  which  is  merely  a 
toxaemia,  is  more  especially  a  bacteriaemia.  The  problem,  therefore,  is  the 
production  of  a  serum  which  is  principally  bactericidal,  though  it  probably 
must  be,  to  a  certain  extent,  antitoxic  as  well. 

Chantemesse,  in  his  latest  reports  upon  the  serum  treatment  of  this  disease, 
claims  that  by  the  use  of  a  serum  taken  from  horses  which  have  been  immu- 
nized by  the  injection  of  a  soluble  enteric  toxin  he  has  reduced  the  death 
rate  to  four  or  five  percent.,  as  against  a  mortality  of  eighteen  percent,  in 
other  hospitals  in  Paris  where  the  cold  bath  treatment  only  is  used.  He 
states  the  interesting  fact  that  patients  profoundly  poisoned  by  the  disease 
should  receive  small  doses  of  the  serum  as  against  the  large  doses  given  in 
mild  infections.  He  uses  cold  bathing  in  connection  with  his  serum  and  con- 
siders the  prognosis  under  this  form  of  treatment  best  when  the  injections 
are  begun  early  in  the  disease. 

Much  experimentation  has  been  done  by  various  observers  along  the  lines 
of  serum  treatment  but  this  apparently  has  resulted  in  the  production  of 
only  a  very  slight  influence  on  the  disease  and,  as  regards  therapeusis,  little 
more  has  been  proven  than  that  the  treatment  is  harmless. 

Treatmetit    by   Elimination    and   Intestinal   Antisepsis.     From    the    time 


1 8  THE    INFECTIOUS    DISEASES. 

that  enteric  fever  was  recognized  as  a  distinct  disease,  and  more  particularly 
since  it  was  demonstrated  to  be  of  bacterial  origin,  the  eliminative 
and  antiseptic  treatment  has  been  foremost  in  the  minds  of  advanced 
clinicians.  The  only  questions  have  been,  can  the  antiseptic  treatment  be 
efficient,  and,  how  shall  we  best  secure  its  efficiency  ?  An  extended  experi- 
ence shows  that  many  patients  may  be  treated  effectively  by  the  use  of  such 
insoluble  antiseptics  as  naphthalene,  the  various  preparations  of  salicylic  acid 
and  bismuth  naphtholate  or  tetraiodophenolphthaleinate.  Of  these  the  two 
bismuth  salts  are  to  be  preferred.  The  bowels  should  be  first  flushed  with 
calomel  followed  by  a  saline,  and  then  the  bismuth  salt  should  be  adminis- 
tered in  divided  doses  of  from  90  to  120  grains  (6.0  to  8.0)  per  day.  If  the 
disease  is  not  inhibited  in  the  first  week  of  the  exhibition  of  these  salts  the 
problem  is  complicated  by  the  fact  that  the  infection  has  become  systemic. 
We  must  now  administer  an  antiseptic  which  will  be  disseminated  as  far  as 
the  blood  goes  and  which  can  permeate  every  organ  and  tissue. 

At  present  the  administration  of  the  compound  solution  of  chlorine  accom- 
plishes the  purpose  better  than  that  of  any  other  drug.  It  should  be  given  in 
doses  of  one  drachm  (4.0)  every  three  or  four  hours.  In  such  dosage  it  may  be 
given  until  complete  disinfection  of  the  alimentary  tract  is  obtained;  not  only 
this;  it  is  also  taken  up  by  the  blood,  as  is  proven  by  the  fact  that  free  chlorine 
has  been  found  post  mortem  in  the  ventricles  of  the  brain,  and  combats  the 
infection  there. 

All  the  chlorine  is  not  changed  in  the  stomach  into  alkaline  chlorides,  but 
some  passes  through  the  intestine  in  its  original  form  for  its  odor  can  be 
detected  in  the  faeces.  It  is  not  irritating  to  the  mucous  membranes  of  the 
gastro-intestinal  tract. 

The  author  considers  that  there  is  nothing  in  medicine  more  striking  than 
the  clearing  up  of  the  tongue,  the  improved  mental  condition,  the  lessened 
local  disturbances  and  the  general  betterment  which  chlorine  brings  about 
in  enteric  fever  and  especially  is  it  effective  in  the  severer  forms  of  the  disease. 

In  concluding  the  discussion  of  the  treatment  by  chlorine  it  may  be  safely 
asserted: 

1.  That  in  the  treatment  of  enteric  fever  chlorine  can  be  safely  admin- 
istered, without  fear  of  digestive  or  other  disturbance,  until  the  alimentary 
tract  has  been  completely  disinfected. 

2.  That  under  its  use  the  tongue  becomes  cleaner,  the  appetite  and  diges- 
tion better,  the  fever  lower  and  the  stools  devoid  of  odor  save  that  due  to  the 
chlorine. 

3.  The  general  strength,  intellectual  processes  and  nervous  conditions  ini- 
prove. 

4.  The  duration  of  the  disease  is  shortened  and  the  patient  usually  pro- 
ceeds to  a  rapid  and  complete  recovery. 


ENTERIC    FEVER.  1 9 

The  mortality  should  not  be  greater  than  2  percent. 

Complications  are  rare  because  this  form  of  treatment  limits  the  infection. 

In  children  it  is  better  to  begin  the  administration  of  chlorine  early  in  the 
disease,  no  preliminary  treatment  by  means  of  the  insoluble  intestinal  anti- 
septics being  necessary  or  advisable. 

During  the  course  of  the  disease  elimination  is  encouraged  by  the  use  of 
high  rectal  irrigations  of  i  gallon  (4  liters)  of  normal  (0.9  percent,  sodium  chlo- 
ride) saline  solution.  The  tube  should  be  gently  passed  into  the  rectum  for  at 
least  a  foot,  the  bag  or  irrigator  should  be  three  feet  above  the  patient, 
and  the  temperature  of  the  solution  112°  F.  (44.5°  C).  The  irrigations  should 
be  given  twice  a  day.  They  hasten  the  elimination  of  toxins,  keep  the  bowels 
active  and  have  a  considerable  stimulant  effect  upon  the  patient. 

If  constipation  is  present  sufficient  magnesiima  sulphate  to  keep  the  bowels 
freely  open  should  be  prescribed. 

Treatment  by  Means  of  Cold  Baths.  At  the  present  time  the  treatment 
of  enteric  fever  by  means  of  the  Brand,  or  more  properly  the  Currie-Jurgensen 
bath  is  enjoying  considerable  vogue.  The  history  of  this  method  is  a  curious 
one.  In  the  early  period  of  the  use  of  this  method  it  was  advocated  because 
it  was  thought  that  it  reduced  the  fever.  When  it  became  apparent  to  anyone 
who  made  careful  observations  that  its  effect  upon  the  fever  was  transient, 
that  almost  as  frequently  the  temperature  rose  after  the  bath  as  fell,  this  theory 
became  untenable  and  was  abandoned.  But  tubbing  was  continued  without 
theory.  Later  the  patients  were  subjected  to  the  bath  on  the  ground  that  it 
was  a  nerve  stimulant.  The  truth  of  this  hypothesis  can  hardly  be  affirmed  or 
denied  for  it  can  neither  be  proven  nor  disproven.  When  this  theory  was 
rejected  the  baths  were  continued  as  before.  The  last  and  present  theory 
is  that  bathing  increases  the  elimination  of  ptomaines.  The  baths  certainly 
are  diuretic,  but  that  they  eliminate  ptomaines  is  incapable  of  proof  because 
at  present  we  have  no  method  by  which  ptomaine  elimination  can  be  accurately 
measured.  It  has  been  said  that  the  urotoxic  co-efficient  is  increased  after 
the  baths,  but  it  is  perfectly  safe  at  the  present  time  to  say  that  until  chem- 
istry shall  afford  a  method  of  obtaining  quantitative  and  qualitative  results 
as  to  the  toxins  found  in  the  urine  all  theorizing  as  to  the  increased  urotoxic 
co-efficient  must  be  absolutely  worthless  as  a  guide  to  clinical  procedure. 

Much  as  the  author  deprecates  the  continued  popularity  of  the  cold  bath 
treatment  it  is  meet  that  it  should  receive  proper  description  in  a  work  of 
this  nature. 

Brand's  original  method  has  been  so  modified  that  the  consensus  of  opinion 
of  the  advocates  of  this  form  of  treatment  seems  to  be  in  favor  of  tub  bathing 
at  a  temperatiu-e  of  from  80^-90°  F.  (26.5°  to  32.5°  C),  although  certain 
authorities  believe  that  tubbing  at  98°  F.  (36.5°  C.)  produces  quite  as  good 
results  and  is  much  less  disturbing  to  the  patient. 


20  THE    INFECTIOUS    DISEASES. 

The  technique  of  the  procedure  may  be  described  as  follows:  To  carry 
out  the  process  properly  at  least  two  attendants  are  necessary,  for  the  patient 
must  be  lifted  into  the  tub  which  is  placed  at  his  bedside.  The  tub  should 
contain  water  enough  to  cover  the  patient  to  the  neck,  the  head  should  be  sup- 
ported upon  a  rubber  air  pillow  attached  to  the  edge  of  the  tub  and  his  com- 
fort will  be  augmented  by  placing  a  rubber  air  cushion  beneath  the  buttocks. 
If  the  initial  plunge  into  the  cold  water  be  disagreeable  the  bath  may  be  begun 
at  a  comfortable  temperature  and  cold  water  may  be  gradually  added  until 
the  temperature  is  reduced  as  low  as  required.  It  is  better,  however,  to  use 
cold  water  from  the  beginning  for  the  effect  sought  is  a  reaction  and  for  this 
a  certain  amount  of  shock  is  necessar}\  The  patient,  wearing  swimming 
trunks  or  covered  by  a  sheet,  should  be  gently  lifted  by  two  attendants  and 
lowered  into  the  water.  Cold  water — 60°  F.  (15.4°  C.)  or  less — should  be 
poured  over  the  head  or  a  frequently  changed  cool  compress  should  be  applied 
to  the  forehead.  The  cold  water  may  be  applied  to  the  head  by  means  of 
an  ordinary  irrigating  apparatus  . 

Vigorous  rubbing  of  the  body  by  the  hands  of  the  attendants  is  an  abso- 
lute necessity.  The  bath  should  last  from  10  to  20  minutes  according 
to  the  reactive  power  of  the  patient.  At  the  end  of  the  procedure  the 
patient  should  be  lifted  from  the  tub  and  placed  on  the  bed — over  which  a 
rubber  sheet  and  a  blanket  have  been  previously  spread — the  water  having 
been  allowed  to  drain  off  for  a  few  seconds  to  prevent  wetting  the  blankets. 
Now,  being  wrapped  in  the  blankets,  he  should  be  thoroughly  dried  by  rub- 
bing. If  the  patient  shows  signs  of  poor  reaction  while  in  the  bath,  such  as 
blueness  of  the  lips  and  extremities  or  decided  shivering,  or  if  the  effect  upon 
the  heart  is  untoward,  the  duration  of  the  bath  should  be  lessened  and  its 
temperature  raised.  In  most  patients  chattering  of  the  teeth  may  be  dis- 
regarded and  cyanosis  of  the  extremities  alone  need  not  be  considered  sufl&cient 
reason  for  stopping  the  bath,  but  if  marked  blueness  of  the  face,  especially 
about  the  nose,  be  noticed,  the  patient  should  be  immediately  taken  from 
the  water.  Before  the  patient  is  put  into  the  bath  and  after  he  is  taken  out 
some  authorities  are  accustomed  to  administer  a  glass  of  wine,  a  half  ounce 
(15.0)  of  whiskey  or  a  half  to  one  drachm  (2.0  to  4.0)  of  the  aromatic  spirit  of 
ammonia,  diluted,  but  these  stimulants  seem  hardly  necessary  as  a  routine 
and  would  better  be  husbanded  against  an  occasion  of  real  need.  During 
the  bath  a  glass  of  cold  water  may  be  allowed. 

The  patient's  reactive  powers  may  be  measured  by  a  tentative  bath  at 
90°  F.  (32.5  C),  reduced  to  80°  F.  (26°  C.)  and  lasting  five  minutes,  and  the 
initial  temperature,  the  reduction  and  the  length  of  the  following  bath  may 
be  determined  accordingly.  If  possible  the  physician  should  be  present 
during  this  bath,  both  to  guard  against  the  possibility  of  shock  and  to  make 
sure  that  the  good  effects  of  the  procedure  are  not  lessened  by  too  early  termi- 


ENTERIC    FEVER.  21 

nation.  If  the  cold  tub  is  not  well  borne  by  the  patient  warm  baths  given 
in  the  same  manner  are  often  followed  by  good  results. 

In  private  practice  the  carrying  out  of  this  method  of  treatment  is  fraught 
with  difficulty  for  obvious  reasons.  It  is  best  managed  by  procuring  an 
ordinary  tin  bath  tub  which  may  be  easily  moved  from  place  to  place.  This, 
as  well  as  the  wheeled  tubs  used  in  hospitals,  should  be  filled  freshly  for  each 
bath. 

The  preparation  of  the  bed  for  the  reception  of  the  patient  after  the  bath 
is  of  utmost  importance.  All  should  be  ready  before  the  beginning  of  the 
procedure,  so  that  should  it  become  necessary  to  terminate  the  bath  suddenly 
there  may  be  no  delay.  Two  warm  blankets  should  be  provided  and  several 
hot  water  bags  as  well,  and  an  ice  cap  should  be  ready  for  the  head.  Under 
the  lower  blanket  should  be  placed  a  piece  of  water  proof  cloth,  over  it  a  warm 
sheet  upon  which  the  patient  should  be  laid  upon  being  Hfted  from  the  tub. 
The  sheet  should  then  be  wrapped  about  him  and  tucked  between  the  arms 
and  body  so  that  no  two  skin  surfaces  shall  come  in  contact.  The  patient  is 
thoroughly  dried  by  being  rubbed  outside  the  sheet.  This  is  then  removed 
and  he  is  allowed  to  lie  between  the  blankets  with  the  hot  water  bottles  against 
his  feet  and  the  ice  cap  upon  his  head. 

About  20  to  30  minutes  after  the  bath  is  over  the  patient  will  have  ceased 
to  be  cold  and  his  temperature  should  be  taken  to  ascertain  the  effect  of  the 
procedure;  it  should  be  taken  again  three  hours  after  the  beginning  of  the 
bath  in  order  to  learn  if  a  second  is  necessary,  it  being  the  custom  to  give  the 
cold  tubs  every  three  hours  if  the  temperature  reaches  102.5°  F.  (39.1°  C.) 
or  more. 

The  fall  in  temperature  following  the  bath  varies  in  different  patients  as  well 
as  in  the  different  weeks  of  the  disease.  In  the  first  week  it  may  not  fall  so 
much  as  one  degree  (F.),  but  in  the  later  weeks  drops  of  from  two  to  three  de- 
grees (F.)  are  common.  In  addition  to  the  lowering  of  the  temperature  the 
bath  is  said  to  mitigate  the  other  symptoms,  increasing  the  strength  of  the 
heart,  and  lessening  the  tendency  toward  cerebral  disturbance. 

Contra-indications  to  bathing  are  few.  The  menstrual  period  and  preg- 
nancy do  not  contraindicate  but  at  the  slightest  sign  of  haemorrhage,  peri- 
tonitis or  perforation  the  procediure  should  be  stopped.  Extreme  heart  weak- 
ness, marked  arteriosclerosis,  old  age,  and  complicating  pneumonia,  pleuritic 
effusion,  or  phlebitis  are  contraindications.  Obese  patients  should  be  bathed 
with  care.  There  are  certain  persons  who,  for  no  apparent  reason,  do  not 
bear  tubbing  well.     In  such  it  is  wise  to  omit  the  process. 

The  Bed  Bath.  In  instances  where  tub  bathing  is  inconvenient  or  impossible 
the  bed  or  slush  bath  may  be  employed.  Many  patients  to  whom  the  cold 
tub  is  almost  unendurable  bear  it  well  and  are  favorably  affected  by  it.  It  is 
given  upon  a  bed  around  the  edges  of  which  rolled  blankets  have  been  placed 


2  2  THE    INFECTIOUS    DISEASES. 

SO  as  to  form  a  sort  of  wall.  Over  this  is  placed  a  rubber  sheet  and  into  the 
trough  thus  formed  several  pails  of  v/ater  are  poured.  The  patient  is  placed 
in  this  and  treated  just  as  when  the  tub  bath  is  employed.  The  bed  bath 
may  be  constructed  also  by  passing  a  piece  of  clothes  line  around  the  head 
and  foot  of  the  bed,  connecting  these  by  two  parallel  ropes  and  throwing  over 
the  whole  a  rubber  sheet  which  is  attached  to  the  rope  by  clothes  pins;  or  a 
rectangular  fence  about  eight  inches  in  height  and  slightly  smaller  than  the 
mattress  may  be  constructed  over  which  a  rubber  sheet  may  be  thrown.  The 
water  from  these  improvised  tubs  is  best  drawn  off  by  a  siphon  made  of  a  few 
feet  of  rubber  hose. 

The  sponge  hath  is  indicated  when  the  temperature  is  hardly  high  enough 
to  warrant  the  more  drastic  tub  bath  and  yet  is  sufficiently  elevated  to  cause 
discomfort.  In  any  case  the  patient  should  receive  two  sponges  daily  for  the 
sake  of  cleanliness.  The  method  is  as  follows :  The  water  may  be  of  various 
temperatures  as  indicated;  often  the  addition  to  it  of  a  little  alcohol  is  grateful  to 
the  patient.  An  ice  cloth  should  be  appUed  to  the  head  and  a  sponge  or  soft 
cloth  wet  just  sufficiently  to  leave  a  thin  film  of  moisture  on  the  skin  is  used; 
this  cools  the  patient  by  rapid  evaporation  and  does  not  wet  the  bed  clothing 
and  with  it  he  is  thoroughly  rubbed,  while  the  other  hand  is  performing 
friction,  and  then  dried,  one  part  at  a  time.  Care  should  be  observed  to 
keep  the  portions  of  the  body  not  being  sponged,  covered.  Particular 
attention  should  be  given  the  back  for  here  the  tissues  retain  heat  longest. 
Proper  reaction  is  evidenced  by  redness  of  the  skin.  No  such  effect  is  pro- 
duced upon  the  temperature  by  sponging  as  by  tubbing. 

The  sprinkle  hath  as  a  method  for  the  reduction  of  temperature  may  be 
considered  to  rival  the  tub  bath.  It  is  better  borne  by  many  patients  and  is 
of  peculiar  adaptation  to  private  practice. 

The  technique  is  as  follows:  The  head  of  the  bed  should  be  raised  about  lo 
inches  from  the  floor,  and,  to  keep  the  mattress  from  sagging,  crosswise  under 
it  should  be  placed  several  boards  as  long  as  the  width  of  the  bed.  The  mattress 
should  be  covered  with  a  rubber  sheet  upon  which  a  pillow  and  ordinary  sheet 
are  adjusted.  The  patient  should  be  stripped  and  sprinkled  with  water  of 
the  desired  temperature  from  a  watering  pot  or  from  an  irrigating  apparatus 
to  the  tube  of  which  a  sprinkling  nozzle  is  fitted.  The  water  as  it  flows  from 
the  foot  of  the  bed  is  received  in  any  large  vessel  and  may  be  used  over  and 
over,  the  proper  temperature  being  maintained  by  the  addition  of  ice.  The 
water  should  not  be  poured  from  too  great  a  height  and  should  be  applied 
chiefly  to  the  abdomen  and  legs.  Rubbing  with  the  hands  should  be  con- 
tinued throughout  the  procedure,  otherwise  the  patient  should  be  dealt  with 
exactly  as  in  tub  bathing. 

The  wet  pack  is  another  useful  hydrotherapeutic  procediu-e  less  unpleasant 
to  the  patient  than  the  tub.      The  body  from  the  axillae  to  the  groins  is 


ENTERIC    FEVER.  23 

wrapped  in  a  sheet  which  is  kept  cool  enough  by  repeated  wettings  to  con- 
trol the  temperature. 

Antipyretic  Drugs.  Certain  drugs  of  this  class,  such  as  antipyrine,  acetphe- 
netidine  acetanilide,  pyramidon,  etc.,  may  be  used  in  excessively  high  tempera- 
tiures  but  they  are  not  to  be  recommended  because  of  the  possibility  of  their 
causing  cardiac  depression.  Neither  do  they,  although  they  may  bring  about 
a  fall  in  temperature,  act  favorably  upon  the  other  symptoms  of  the  disease. 
Lactophenine,  in  daily  dosage  of  60  to  75  grains  (4.0  to  5.0)  may  cause  a 
prompt  fall  in  temperature,  quiets  the  nervous  system  and  induces  sleep. 
Quinine  and  euquinine  also  cause  the  temperature  to  drop,  but  none  of  this 
class  of  drugs  affects  the  course  of  the  disease  and  they  are  not  to  be  recom- 
mended save  as  adjuncts  to  other  forms  of  treatment. 

Treatment  by  intestinal  antiseptics  other  than  chlorine  has  been  frequently 
advocated.     Among  the  drugs  discussed  in  this  connection  may  be  mentioned: 

Phenyl  salicylate  (salol)  in  doses  of  from  5  to  10  grains  (0.33  to  0.66)  four 
to  five  times  a  day.  The  possibility  of  injuring  the  kidneys  more  than  over- 
balances any  possible  good  effect  that  this  drug  can  accomphsh. 

Thymol  in  the  same  dosage  is  open  to  the  same  objections. 

Calomel  as  an  intestinal  antiseptic -is  practically  inert  and  the  good  effects 
reported  from  its  use  have  doubtless  been  due  to  the  free  purgation  in  the 
early  period  of  the  disease  which  its  exhibition  induces. 

Betanaphthol  in  5  to  10  grain  (0.33  to  0.66)  doses  three  or  four  times  daily, 
is  claimed  to  be  capable  of  causing  intestinal  antisepsis  without  toxic  symp- 
toms. Its  use  is  recommended  in  combination  with  bismuth  salicylate  when 
there  is  diarrhoea,  with  magnesium  sulphate  when  there  is  constipation.  It 
is  asserted  that  under  the  influence  of  this  drug  there  is  less  tendency  to  ab- 
dominal pain  and  tympanites,  the  tongue  becomes  clear  and  the  stools  odor- 
less, convalescence  advances  rapidly  and  there  is  a  diminished  tendency  to 
complications. 

Phenol  and  tincture  of  iodine,  one  part  to  two  in  doses  of  one  to  three 
minims  (0.065  to  0.2)  well  diluted,  three  to  six  times  a  day  have  been  recom- 
mended. Naphthalene  is  objectionable  on  account  of  its  large  dosage,  un- 
pleasant taste  and  liability  to  cause  strangury.  Beer  yeast,  three  teaspoonsful 
(12.0)  in  milk  per  day,  has  been  given  in  the  hope  that  its  micro-organisms 
might  inhibit  the  growth  of  the  tj-phoid  bacilli  in  the  intestine,  but  little  is  to 
be  accomplished  by  this  agent  save  a  checking  of  the  diarrhoea. 

Acetozone  is  the  commercial  name  given  to  a  mixture  of  benzoyl-acetyl 
peroxide,  an  inert  absorbent  substance.  It  is  administered  as  an  intes- 
tinal antiseptic,  the  daily  dosage  being  10  to  20  grains  (0.66  to  1.33)  dissolved 
in  a  quart  of  water.  Various  observers  have  reported  upon  this  prepara- 
tion, claiming  that  when  taken  early  in  the  disease  and  in  large  amounts 
the  course  is  shortened  to  10  to  12  days.     Also  under  its  influence  the  ab- 


2  4  THE    INFECTIOUS    DISEASES. 

dominal,  nervous  and  other  symptoms  are  less  marked  than  usual.  There 
is  much  difficulty  in  inducing  patients  to  take  sufficient  amounts  for  long 
enough  periods  of  time. 

Treatments  by  Means  of  Intestinal  Antiseptics  and  Free  Elimination.  The 
object  of  these  methods  is  to  render  the  alimentary  tract  as  aseptic  as  possible 
and  to  remove  without  delay  the  cause  and  products  of  the  infection.  As 
far  as  the  antiseptic  part  of  the  treatment  is  concerned  it  differs  in  no  way 
from  the  methods  hitherto  described,  but  added  to  these  is  the  free  exhibition 
of  purgatives,  which  are  given  to  carry  off  the  faecal  accumulations,  the 
patients  being  encouraged  to  drink  large  quantities  of  fluid  to  replace  that 
removed  by  purgation. 

The  simplest  of  these  forms  of  treatment  is  as  follows:  This  consists  of 
the  daily  administration  of  calomel  in  ^  to  ^  grain  (0.016  to  0.032)  every 
half  hoiir  up  to  six  doses;  two  or  three  hours  later  one-half  ounce  (15.0)  of 
Epsom  or  Rochelle  salts  is  given.  The  object  is  to  bring  about  three  to.  four 
free  movements  per  day.  Phenyl  salicylate  (salol)  in  five  grain  (0.33)  doses, 
every  three  hours,  is  the  antiseptic  used  in  connection  with  this  treatment. 
The  claims  are  not  excessively  extravagant,  but  it  is  believed  that  under  this 
treatment  haemorrhage  and  perforation  are  rendered  less  frequent.  The  possi- 
bility of  salivation  from  the  calomel  must  be  considered,  but  it  is  not  likely  to 
take  place,  probably  because  of  the  frequent  movements  from  the  bowels. 

Another  method  of  treatment  which  at  one  time  created  a  considerable 
amount  of  discussion  is  as  follows:  Tablets  consisting  of  podophyllum  resin 
1-960  grain  (0.00067),  calomel  1-16  grain  (0.004),  guaiacol  carbonate  1-16  grain 
(0.004),  menthol  1-16  grain  (0.004),  eucalyptol,  q.s.  were  ordered.  One  of  these 
tablets  was  given  every  15  minutes  during  the  first  24  hours  and  in  larger 
doses  during  the  second  day,  if  necessary,  until  at  least  five  or  six  free  defae- 
cations  had  taken  place  during  the  second  and  third  days.  On  the  third  or 
fourth  day  tablets  containing  podophyllum  resin  i-g6o  grain  (0.00067),  calomel 
1-16  grain  (0.004),  guaiacol  carbonate  ^  grain  (0.016),  menthol  1-16  grain 
(0.004),  thymol  1-16  grain  (0.004),  eucalyptol  q.s.  were  prescribed;  one  every 
two  or  three  hours.  Both  these  tablets  were  given  at  longer  intervals  if  there 
was  a  fall  in  temperature.  On  the  fourth  or  fifth  day  guaiacol  carbonate 
three  grains  (0.2),  thymol  one  grain  (0.065),  menthol  J  grain  (0.033),  eucal- 
yptol five  minims  (0.33)  were  administered  in  capsules,  one  every  three 
hours  alternating  with  the  tablets.  This  plan  of  treatment  in  most  instances 
failed  to  accomplish  the  result  claimed  for  it  and  is  now  in  little  vogue. 

Treatment  of  Special  Conditions  and  Sympto7ns.  The  mouth  and  tongue 
should  be  kept  clean  by  the  employment  of  regular  and  frequent  washings 
with  diluted  liquor  antisepticus,  tincture  of  myrrh,  etc.  A  very  useful  mouth 
wash  consists  of  equal  parts  of  liquor  antisepticus,  hydrogen  dioxide  solution, 
lime  water  and  water.    The  mouth  should  be  cleansed  after  every  administra- 


ENTERIC    FEVER.  25 

tion  of  food  and  there  is  no  contraindication  to  the  use  of  the  tooth  brush. 
Sordes  and  coating  upon  the  tongue  may  be  removed  by  cotton  swabs  wet 
in  one  of  the  above  mentioned  solutions.  A  convenient  tongue-scraper  may  be 
constructed  of  a  piece  of  whale  bone  bent  into  a  loop.  In  cases  where  the 
tongue  is  extremely  dry  the  "  tongue-bath  "  often  affords  much  relief.  This 
consists  simply  in  holding  the  mouth  full  of  fluid  for  several  moments.  In 
this  way  considerable  moisture  is  absorbed  by  the  mucous  membranes. 

Heart  Weakness.  In  this  condition  it  is  better  not  to  use  alcohol  unless 
the  patient  has  been  accustomed  to  the  stimulant  in  health.  In  such  a  case 
it  may  be  employed  (brandy  or  whiskey)  in  doses  necessary  to  produce  the 
desired  effect.  As  a  heart  stimulant  strychnine — 1-60  to  1-15  of  a  grain 
(0.00 1  to  0.004)  depending  upon  the  condition  to  be  met — is  the  stimulant 
of  choice.  Extreme  heart  weakness  may  necessitate  the  additional  employ- 
ment of  digitalis — the  tincture  5  to  10  minims  (0.33  to  0.66) — glyceryl  nitrate 
— i-ioo  to  1-50  of  a  grain  (0.0006  to  0.0012) — or  aromatic  spirit  of  ammonia — 
one  to  two  drachms  (4.0  to  8.0.)  Collapse  may  be  treated  by  hypodermatic 
injections  of  camphor — one  grain  (0.065) — '^^  olive  oil  or  aether — 15  minims 
(i.o).  Marked  asthenia  may  necessitate  the  intravenous  infusion  or  hypo- 
dermatic injection  of  normal  (0.9  percent.)  sodium  chloride  solution. 

Symptoms  Referable  to  the  Nervous  System.  The  headache  and  general 
pains  of  the  onset  may  be  mitigated  by  antipyrine  salicylate  in  10  grain  (0.66) 
doses  every  two  hours,  and  by  hot  or  cold  appHcations.  The  delirium  may 
be  controlled  by  the  use  of  the  ice  cap,  and  various  sedatives,  sodium  bromide 
^  to  I  drachm  (2.0  to  4.0),  sulphonmethajae  (sulphonal)  15  to  20  grains 
(1.0  to  1.33),  chloralformamide  20  to  30  grains  (1.33  to  2.0),  sulphonethyl- 
methane  (trional).  10  to  15  grains  (0.66  to  i.o);  hydrated  chloral  or 
morphine  may  be  employed  as  a  last  resort,  the  latter  best  hypodermatically 
as  Magendie's  solution,  10  drops  (0.66). 

Tympanites  may  be  lessened  by  the  very  careful  introduction  of  a  rectal  • 
tube,  through  which  large  quantities  of  gas  are  often  voided,  and  by  the 
internal  administration  of  oleum  terebinthinae,  5  to  10  minims  (0.33  to 
0.66)  in  capsule.  The  food  should  be  diminished  in  quantity  as  the  meteor- 
ism  is  the  result  of  fermentative  processes.  High  rectal  irrigations  of  nor- 
mal saline  are  also  useful  in  this  connection. 

Diarrhoea,  if  obstinate,  may  usually  be  controlled  by  the  use  of  bismuth, 
with  the  addition  of  opium  if  necessary. 

Constipation  is  best  treated  by  the  use  of  saline  enemata,  though  certain 
observers,  as  will  have  been  noticed  in  the  foregoing  sections,  have  no  objection 
to  the  use  of  calomel  and  other  purgatives. 

Bed  sores  should  never  be  allowed  to  occur  and  may  be  prevented  by  atten- 
tion to  the  points  where  they  are  likely  to  appear.  The  strictest  cleanliness 
must  be  maintained  about  the  back  of  the  heels  and  over  the  buttocks  and 


26  THE    INFECTIOUS    DISEASES. 

sacrum.  The  sheets  must  be  kept  smooth  and  the  bed  thoroughly  clean 
and  free  from  crumbs,  moisture  and  contamination  from  the  rectal  or  vesical 
discharges.  In  addition  to  the  maintenance  of  careful  cleanliness,  measures 
should  be  taken  to  harden  the  skin  of  the  susceptible  parts.  To  insure  a  good 
blood  supply  to  these  the  patient  should  be  turned  upon  his  side  several  times 
a  day  and  the  skin  of  the  back  thoroughly  rubbed  with  a  dry  towel  and  dusted 
with  powdered  talc.  Applications  rubbed  into  the  skin  to  harden  it,  such  as 
salt,  two  drachms  (8.0),  to  whiskey,  one  pint  (^  litre),  or  a  dilute  solution  of  lead 
subacetate  may  be  employed.  When  the  skin  becomes  red  and  irritated,  but  is 
still  unbroken,  it  should  be  painted  with  a  solution  of  silver  nitrate,  20  grains 
(1.33)  to  one  ounce  (30.0)  of  water.  When  the  bed  sore  has  appeared,  with 
the  object  of  preventing  its  spread  and  of  accelerating  its  cure,  the  patient 
must  be  so  placed  as  to  take  all  weight  from  the  affected  part;  this  may  be 
accomplished  by  the  use  of  a  rubber  bed  ring.  The  sore  itself  must  be  kept 
clean  by  swabbing  with  i  to  5,000  mercury  bichloride  solution  and  dusted  with 
iodoform.  A  dressing  of  zinc  oxide  ointment  spread  upon  gauze  may  be 
applied.  In  marked  instances  the  use  of  the  water  bed  may  become  neces- 
sary. If  the  sore  spreads  or  burrows  through  the  surrounding  parts  free 
opening  and  thorough  irrigation  are  indicated. 

Complications  should,  in  general,  be  treated  as  when  occurring  independ- 
ently, but  the  treatment  of  intestinal  haemorrhage,  peritonitis  and  perfora- 
tion needs  special  consideration. 

Upon  the  appearance  of  any  symptom  suggestive  of  hcemorrhage  all  hydro- 
therapeutic  measures  should  be  stopped  immediately  and  absolute  quiet 
insisted  upon.  An  ice  coil  should  be  applied  to  the  abdomen  and  the  food 
should  be  of  the  most  non-irritating  character;  it  is  often  wise  to  stop  feeding 
entirely  for  six  or  eight  hours.  If  the  haemorrhage  is  extreme  a  hypodermatic 
injection  of  from  J  to  ^  of  a  grain  (0.016  to  0.022)  of  morphine  should  be  given 
and  the  foot  of  the  bed  should  be  elevated.  The  administration  of  morphine 
or  opium  has  the  disadvantage  that  it  may  mask  the  symptoms  of  a  concur- 
rent perforation  of  the  intestine  and  on  this  ground  certain  clinicians  con- 
sider it  better  omitted.  If  symptoms  of  collapse  are  present  hypodermatic 
stimulation  by  means  of  aether  or  camphor  with  sterile  oil  is  necessary.  In 
this  connection  hypodermatoclysis  of  hot  normal  saline  solution  or  direct 
infusion  into  a  vein  is  also  useful.  The  most  efficient  drug  in  the  control  of 
the  haemorrhage  is  calcium  lactate  in  doses  of  20  grains  (1.33)  three  times 
daily.  Calcium  chloride  is  also  effective,  both  these  substances  having  a 
decided  influence  in  increasing  the  coagulability  of  the  blood.  Their  use 
should  not  be  continued  for  more  than  three  or  four  days  for  their  more  pro- 
tracted administration  is  likely  to  result  in  a  diminution  of  the  blood's  coagu- 
lability. Gelatin  in  doses  of  75  to  120  grains  (5.0  to  8.0)  has  been  recom- 
mended in  the  treatment  of  haemorrhage,  and  ergot — ^  drachm  (2.0)  of  the 


ENTERIC    FEVER.  27 

fluid  extract^also  has  its  advocates.  Internal  styptics  such  as  tannic  and 
gallic  acids,  lead  subacetate,  etc.,  may  be  employed  but  their  effect  is  prob- 
lematical. 

Perforation  of  the  intestine  and  peritonitis  necessitate  early  operative  treat- 
ment and  by  this  means  many  patients  are  now  saved  who  under  less  radical 
treatment  would  formerly  have  died.  The  earlier  the  operation  is  under- 
taken after  the  establishment  of  the  diagnosis  the  better  are  the  chances  of 
recovery.  Operation  should  be  performed  even  in  desperate  instances  and 
when  the  condition  is  obscure  an  exploratory  incision  is  advisable,  the  resis- 
tance to  the  shock  of  operation  being  usually  good  in  t)^hoid  patients. 

Such  surgical  complications  as  periostitis  and  cholecystitis  often  recover 
without  operation  but  when  the  presence  of  pus  is  clearly  demonstrable 
radical  treatment  should  be  undertaken. 

Neuritis  following  enteric  fever  is  frequently  characterized  by  paralysis 
and  although  its  symptoms  may  persist  for  months,  as  a  rule  recovery  takes 
place  under  the  influence  of  massage,  electricity  and  general  tonic  treat- 
ment. 

The  so-called  typhoid  spine  may  prove  an  obstinate  sequel  of  the  disease; 
it  is  usually  accompanied  by  a  nevurotic  condition  of  the  patient  and  requires 
practically  the  same  treatment  as  neurasthenia,  namely,  rest  in  an  institution 
where  anxious  and  sympathetic  friends  are  not  given  access  to  the  patient, 
hydrotherapeutic  measures,  massage  and  proper  exercises.  The  application 
of  the  acutal  cautery  may  prove  effective. 

During  convalescence  the  patient  should  be  guarded  against  recrudescences 
and  relapses,  the  treatment  of  which,  should  they  occur,  is  practically  the 
same  as  that  of  the  original  attack. 

With  regard  to  diet  it  may  be  stated  that  if  the  patient's  nutrition  remains 
good  it  is  best  to  allow  no  solid  food  before  the  7th  to  the  loth  day  after  the 
return  of  the  temperature  to  normal;  solid  food  may  be  permitted  earlier  than 
this  to  patients  who  are  weak  and  much  emaciated  and  in  certain  instances 
a  persistent  slight  afternoon  fever  has  been  known  to  subside  upon  giving 
the  patient  simple  solid  food.  The  danger  of  inducing  perforation  by  the 
too  early  administration  of  solids,  however,  must  not  be  forgotten  and  the 
same  is  true  of  too  early  muscular  exertion.  The  first  solid  foods  usually 
allowed  are  scraped  raw  beef  sandwiches,  soft  boiled  eggs,  milk  toast,  boiled 
rice  and  other  cereals.  These  should  be  given  tentatively  and  with  caution 
at  first,  and  if  no  ill-effects  follow,  their  quantity  may  be  increased  and  a  gradual 
return  to  ordinary  diet  permitted. 

As  stated,  muscular  exertion  should  be  undertaken  with  great  care  and 
any  excess  of  this,  as  well  as  of  emotional  excitement,  should  be  studiously 
guarded  against  upon  the  ground  that  recrudescence  may  follow. 

Protracted  diarrhoea  is  often  due  to  the  presence  of  an  unhealed  ulceration, 


28  THE    INFECTIOUS    DISEASES. 

and  in  view  of  possible  perforation,  the  patient  should  be  kept  in  bed  and  on 
a  fluid  diet  until  there  is  evidence  that  the  lesion  has  disappeared  which  will 
usually  take  place  if  bismuth  naphtholate  or  tetraiodophenolphthaleinate  is 
prescribed  in  doses  of  about  5  grains  (0.33)  three  or  four  times  daily  in  con- 
nection with  astringent  injections  such  as  those  advised  for  the  treatment 
of  ulcerative  colitis. 

Obstinate  constipation  is  better  treated  by  simple  enemata  than  by 
drugs. 

With  regard  to  the  time  when  the  patient  should  be  first  allowed  to  sit  up, 
in  general  it  may  be  said  that  by  the  end  of  the  first  week  after  the  return  of 
the  temperature  to  normal  he  may  be  moved  to  a  chair  for  a  gradually  increased 
time  each  day  and  after  a  few  days  he  may  venture  upon  his  feet  and  walk 
about*  slowly.     Little  by  little  he  may  resume  his  ordinary  mode  of  life. 

PARATYPHOID  FEVER. 

This  is  a  term  applied  to  a  group  of  diseases  which  in  clinical  course  closely 
resemble  true  enteric  fever. 

Etiology.  The  cause  of  these  affections  is  a  micro-organism  intermediate 
between  the  bacillus  typhosus  and  the  bacillus  coli,  and  which  closely  simulates 
or  is  identical  with  the  paracolon  bacillus.  The  modes  of  infection  are  prob- 
ably similar  to  those  of  enteric  fever. 

Pathology.  The  morbid  changes  found  in  these  affections  consist  of 
constant  splenic  enlargement  and  intestinal  ulcerations  resembling  those 
of  dysentery  rather  than  those  of  enteric  fever.  The  solitary  and  agminated 
follicles  and  the  mesenteric  glands  are  not  involved.  Rose  spots  have  been 
observed. 

Symptoms.  The  incubation  period  is  shorter  than  that  of  enteric  fever 
and  the  onset,  which  may  be  preceded  for  several  days  by  prodromata  such  as 
malaise,  headache  and  torpor,  is  usually  more  sudden.  The  lethargy  appears 
earlier  and  this  symptom  as  well  as  the  headache  is,  as  a  rule,  more  marked. 
The  temperature  rises  more  rapidly  than  in  enteric  fever;  an  initial  temperature 
as  high  as  104°  F.  (40°  C.)  has  been  noted.  Splenic  enlargement  and  rose 
spots  occur.  The  course  of  the  disease  varies;  it  may  be  short  or  in  other 
instances,  prolonged;  convalescence  is  usually  shorter  than  in  enteric  fever; 
relapses  may  occur. 

The  differentiation  from  enteric  fever  is  based  upon  the  absence  of  the 
Widal  reaction  and  the  causative  micro-organism  may  be  cultivated  from 
the  faeces,  urine,  the  blood  and  from  the  rose  spots. 

The  disease  may  result  fatally,  but  most  patients  recover. 

The  prevention  of  paratyphoid  infections  is  identical  with  that  of  enteric 
fever. 


MOUNTAIN    FEVER.  29 

Treatment.  This  is  essentially  the  same  as  that  of  enteric  fever  with  the 
exception  that  the  serum  employed  in  specific  treatment  must  of  necessity  be 
a  product  of  the  growth  of  the  paracolon  bacillus. 

MOUNTAIN   FEVER. 

Synonyms.     Rocky  Mountain  Fever;  Spotted  Fever. 

Definition.  An  acute  infectious  disease  characterized  by  a  rather  sudden 
onset  with  a  chill,  a  purpuric  eruption  and  a  high  fever  terminating  in  from 
two  to  seven  weeks  by  lysis. 

.Etiology.  The  disease  occurs  in  the  Rocky  ^lountain  regions  of  Idaho, 
Montana,  Wyoming  and  Nevada;  it  is  especially  common  in  the  Bitter  Root 
Valley  and  along  the  course  of  the  Snake  River.  It  is  most  prevalent  in  the 
spring  and  early  summer  months,  being  very  rarely  observed  at  other  seasons. 
Males  are  more  commonly  affected  than  females,  probably  because  the 
occupations  and  habits  of  the  former  render  them  more  liable  to  infection, 
and  the  disease  most  usually  attacks  individuals  in  early  or  mature  adult 
life.  It  occurs  less  frequently  in  children.  Persons  who  live  in  farming  or 
grazing  districts  and  those  who  spend  most  of  their  time  in  the  open  air, 
as  carpenters,  engineers,  bridge  builders  and  individuals  of  similar  occu- 
pation who  are  engaged  in  railroad  and  canal  construction,  seem  most  prone 
to  acquire  the  infection. 

Certain  observers  who  reside  in  regions  w'here  the  disease  is  frequently 
seen  have  considered  its  specific  cause  to  be  the  pyroplasma  hominis,  an 
organism  nearly  related  to  the  pyrosoma  higeminum,  the  cause  of  Texas  cattle 
fever;  they  state  that  this  parasite  is  found  within  the  body  of  the  red  blood 
cells  of  individuals  suffering  from  the  disease  and  is  transmitted  to  the  patient 
by  means  of  the  bite  of  a  variety  of  tick,  the  dermacentor  reticulatus. 

Prolonged  study  of  the  blood  and  red  cells  of  infected  subjects  by  other 
observers  has  failed  utterly  to  show  the  presence  of  p\Toplasmata  and  has 
left  the  true  cause  of  the  disease  in  doubt;  it  seems,  however,  probable  that 
the  specific  organism,  if  present  in  the  blood,  must  be  one  very  difficult  of 
demonstration  and  one  necessitating  the  employment  of  special  methods  of 
experimentation  for  its  identification. 

Inoculation  experiments  with  the  blood  of  patients  suft'ering  from  the 
affection  have  proven  that  the  disease  may  be  transmitted  to  guinea-pigs 
and  monkeys  since  the  fever,  duration  and  skin  manifestations  exhibited  by 
these  animals  after  such  inoculations  simulate  closely  the  symptoms  exhibited 
by  the  human  being. 

Even  if  the  theory  that  mountain  fever  is  not  due  to  a  pyroplasma,  and  in 
the  light  of  our  present  knowledge  it  would  seem  that  it  is  not,  it  is  possible 
that  the  disease  may  be  transmitted  by  means  of  a  tick  bite  since  it  is  prob- 


3° 


THE    INFECTIOUS    DISEASES. 


al)le  that  ticks  may  act  as  the  hosts  of  other  pathogenic  micro-organisms  than 
pyroplasmata. 

Pathology.  The  morbid  changes  observed  upon  autopsy  consist  of  the 
cutaneous  manifestations,  which  will  be  described  in  a  later  paragraph.  In 
guinea-pigs,  in  addition  to  the  skin  phenomena,  enlargement  and  a  hsemor- 
rhagic  condition  of  the  scrotum  have  been  observed  by  Ricketts,  together  with 
swelling  of  the  testicles,  congestion  of  the  epididymis,  retention  of  the  urine, 
distention  of  the  seminal  vesicles,  congestion  of  the  kidneys  and  suprarenal 
glands,  swelling  and  congestion  of  the  spleen  and  liver  and  an  enormous  en- 
gorgement of  the  right  heart  and  venous  system.  Meningitis  and  localized 
inflammatory  conditions  were  observed  in  instances  in  which  the  skin  of  the 
swollen  scrotum  had  become  gangrenous  and  there  was  consequent  staphy- 
lococcus infection  of  the  underlying  tissue. 

Symptoms.  The  period  of  incubation  is  indefinite  but  probably  varies 
from  three  to  ten  days;  if  the  tick  bite  is  a  factor  in  the  aetiology  of  the  disease 
the  symptoms  may  appear  very  soon  after  the  infection,  for  patients  have  been 
reported  who  have  exhibited  the  heads  of  ticks  imbedded  in  the  skin.  The 
prodromal  symptoms  consists  of  malaise,  nausea  and  sensations  of  cold. 
The  invasion  of  the  disease  is  marked  by  a  distinct  chill,  followed  by  an  abrupt 
rise  of  temperature  which  by  the  second  day  reaches  103°  to  104°  F.  (39.5°- 
40°  C.)  and  by  the  eighth  to  the  tenth  day  may  increase  to  an  afternoon  maxi- 
mum of  105°  to  107°  F.  (4o.5°-4i.6°  C).  The  morning  temperature  is  slightly 
lower  than  that  of  the  evening.  About  the  middle  of  the  second  week  the 
temperature  falls  by  lysis,  usually  reaching  normal  by  the  fourteenth  day. 
With  the  initial  rise  in  temperature  there  is  generally  pain  in  the  body  and 
limbs;  during  the  second  week  nose-bleed,  more  or  less  severe  in  character, 
occurs;  the  tongue  is  coated  down  the  middle,  red  at  the  tip  and  edges  and 
in  severe  infections  may  become  dry,  brown  and  cracked;  sordes  may  be 
observed;  nausea  and  vomiting  and  usually  constipation  are  present.  The 
urine  is  scanty,  dark,  and  contains  an  increased  amount  of  urates;  albumin 
and  casts  may  be  present.  The  spleen  and  liver  are  increased  in  size  and  the 
conjunctivae  may  be  of  sub-icteroid  hue.  The  pulse  is  weak  and  rapid ;  the 
respirations  are  rapid  and  regular  but  shallow.  They  may  reach  60  per 
minute  but  are  usually  about  40.  Bronchitis  may  develop  at  the  end  of  the 
first  week.  In  severely  infected  patients  the  mental  condition  may  resemble 
that  of  enteric  fever.  The  leucocytes  may  be  slightly  increased,  there  is  de- 
struction of  the  red  cells  and  diminution  in  the  amount  of  haemoglobin. 

The  eruption  appears  from  the  third  to  the  fifth  day,  first  upon  the  wrists, 
ankles  or  back,  thence  it  spreads  to  the  arms,  legs,  forehead  and  body,  the 
abdomen  being  last  involved.  The  spots  may  appear  so  rapidly  as  to  cover  all 
the  skin  within  twelve  hours,  but  usually  two  to  three  days  pass  before  the 
height  is  reached.     The  rash  first  consists  of  bright  red  circular  spats  from 


MOUNTAIN    FEVER.  3 1 

the  size  of  a  pin  point  to  that  of  a  pea  and  resembles  the  eruption  of  enteric 
fever;  the  spots  are  not  elevated  and  in  the  beginning  disappear  on  pressure; 
they  may  be  tender  and  in  severe  types  of  the  disease  are  dark  blue  or  purplish 
in  color,  and  increase  in  size  until  the  skin  takes  on  a  mottled  appearance; 
before  disappearing  they  may  assume  a  greenish-yellow  hue.  The  spots  begin 
to  fade  at  the  end  of  the  first  week  and  lose  their  petechial  character  as  the 
fever  declines.  Desquamation  begins  during  the  third  week  but  the  spots 
may  not  wholly  disappear  for  weeks  or  months.  The  skin  may  become 
jaundiced  or  gangrenous  over  the  elbows,  fingers,  toes  or  scrotum.  In  marked 
infections  the  spots  coalesce  and  the  skin  takes  on  a  mottled  appearance 
which  is  quite  typical  of  this  disease. 

The  diagnosis.  The  appearance  of  the  patient  is  quite  characteristic 
and  those  who  have  seen  a  few  patients  suffering  from  it  find  little  difficulty 
in  recognizing  the  disease.  Typhus  fever  occurs  among  those  who  live  in 
poor  sanitary  surroundings  in  crowded  city  districts  and  in  those  closely 
confined  in  ships,  jails  and  the  like.  Epidemic  cerebrospinal  meningitis 
is  characterized  by  the  presence  of  typical  meningeal  symptoms  and  has  a 
specific  bacteriological  aetiology.  Purpura  ha^morrhagica  may  be  differ- 
entiated by  its  history  and  the  accompanying  scorbutic  or  rheumatic  mani- 
festations. The  fact  that  the  Widal  and  the  Ehrlich-diazo  reactions  and 
bacteriologic  examinations  are  negative  will  assist  in  separating  mountain 
from  enteric  fever. 

The  prognosis.  The  severity  of  the  affection  is  apparently  commen- 
surate with  the  skin  eruption  (Mayo).  In  marked  types  of  the  infection  the 
skin  of  the  scrotum  and  thighs  becomes  much  darkened,  areas  of  gangrene 
make  their  appearance,  and  in  such  instances  death  usually  takes  place  here 
as  it  often  does  in  those  patients  who  exhibit  other  symptoms  of  profound 
toxaemia,  such  as  high  temperature,  cardiac  weakness  and  cerebral  manifesta- 
tions. In  the  Bitter  Root  Valley  the  disease  is  particularly  fatal,  84  deaths  in 
121  instances  of  the  affection  having  been  reported.  Death  usually  occurs 
during  the  third  week,  in  some  instances  complications,  especially  pneu- 
monia, being  responsible. 

Prevention.  The  districts  in  which  the  disease  is  common  should  be 
avoided  during  the  months  in  which  mountain  fever  is  prevalent.  Measures 
to  avoid  tick  bites  should  be  taken  and  when  these  have  taken  place  the  insect 
should  be  at  once  removed  by  the  application  of  kerosene,  ammonia  or  tur- 
pentine and  the  wound  cauterized  by  pure  phenol. 

Treatment.  This  is  in  general  symptomatic.  The  employment  of  quinine 
given  in  large  doses  hypodermatically  has  given  favorable  results  in  a  few 
instances.  The  fever  may  be  controlled  by  the  hydrotherapeutic  measures 
indicated  in  enteric  fever;  the  bowels  should  be  kept  open,  and  elimination 
by  means  of  the  skin  and  kidneys  should  be  assisted  by  the  usual  method 


32  THE    INFECTIOUS    DISEASES. 

applicable  in  infectious  febrile  diseases;  the  severe  pains  may  be  relieved 
by  means  of  the  administration  of  Dover's  powder  or  small  doses  of  morphine, 
preferably  given  by  hypodermatic  injection. 

The  patient's  strength  and  nutrition  should  be  maintained  by  means  of 
easily  digestible  fluid  food;  fortunately  the  digestive  tract  does  not  appear  to 
require  such  careful  management  as  in  enteric  fever,  consequently  the  feeding 
is  a  more  simple  matter  than  in  this  latter  disease. 

The  nursing  and  general  management  of  the  patient  should  be  carried 
out  along  the  lines  suggested  in  the  section  on  the  treatment  of  enteric  fever. 

Intermittent  Tick  Fever.  Under  this  term  Kieffer  has  recently  described 
what  he  considers  to  be  a  form  of  ixodiasis  which  has  been  observed  by  him 
in  the  neighborhood  of  Fort  D.  A.  Russell,  Wyoming.  He  reports  seven 
instances  of  the  disease,  from  which  he  concludes  that  it  appears  necessary 
to  produce  the  infection  that  the  tick  should  fasten  itself  to  the  skin  of  the 
patient.  It  also  seems  probable  that  the  number  of  the  insects  biting  the  patient 
has  some  influence  upon  the  severity  of  the  attack  to  follow.  In  all  the  patients 
observed  there  was  distinct  history  of  tick  bites  as  well  as  indubitable  evi- 
dence of  the  bite  at  the  place  where  the  insect  had  fastened  itself.  At  these 
points,  in  a  number  of  the  patients,  small  nodules  were  observed;  these  persisted 
for  weeks,  were  firm,  pale  in  color,  entirely  painless,  and  varied  in  size  from 
that  of  a  pea  to  that  of  a  small  marble.  In  other  instances  the  site  of  the 
attachment  of  the  insect  was  marked  by  a  small  red  papule  in  some  of  which 
the  rostrum  of  the  tick  was  demonstrable.  Specimens  of  the  insect  examined 
by  Dr.  C.  W.  Stiles,  of  the  Public  Health  and  INIarine-Hospital  Service,  were 
proven  to  be  identical  with  the  dermacentor  occidentalis. 

The  patients  were  affected,  in  general,  in  a  corresponding  manner.  After 
a  period  of  incubation  varying  from  three  to  seven  days,  during  which  pro- 
dromal symptoms  consisting  of  headache,  vague  pains,  nausea  and  vomiting 
are  present,  the  disease  is  ushered  in  by  a  severe  chill  lasting  from  two  to 
three  hours.  It  is  not  characterized  by  chattering  of  the  teeth  and  shivering 
like  the  chill  of  malaria,  but  is  associated  with  more  pain  and  discomfort,  and 
the  patient  seems  to  suffer  quite  as  much  as  in  the  painful  stages  of  influenza 
or  dengue.  The  pains  affect  chiefly  the  head  and  the  bones  and  joints. 
Following  or  accompanying  the  chill  there  is  an  elevation  of  temperature 
which  reaches  103°  to  104°  F.  (39.4°  to  40°  C).  The  fever  remains  high,  as  a 
rule,  for  forty-eight  hours,  but  in  some  instances  persists  for  but  half  this 
period,  and  is  followed  by  a  remission  during  which  the  temperature  drops 
to  normal  or  approaches  this  point.  With  the  remissions  the  pains  disappear 
and  the  patient,  whfle  he  feels  weak  and  exhausted,  is  otherwise  comfortable. 
The  temperature  remains  normal  for  about  forty-eight  hours  when  the  second 
chill  begins  and  is  followed  by  a  febrile  movement.  This  paroxysm  termin- 
ates  in   a   manner   similar  to  the  first.     Succeeding  paroxysms  are  usually 


TYPHUS    FEVER.  33 

milder  in  degree.  Rarely  there  is  a  febrile  movement  lasting  one  day  but 
here  there  is  an  intermission  lasting  three  days. 

Other  symptoms  are  abdominal  pain  and  general,  but  not  very  marked, 
tenderness.  Tympanites  sometimes  is  observed.  The  liver  is  not  demon- 
strably increased  in  size  but  there  is  early  moderate  enlargement  of  the  spleen 
and  the  regions  of  these  organs  may  be  rather  more  tender  than  other  areas 
of  the  abdomen.  The  urine  is  usually  concentrated  and  high  colored  but 
is  in  no  way  typical.     No  skin  eruption  has  been  noted. 

The  blood  showed  absolutely  no  agglutination  reaction  to  the  typhoid 
bacillus  and  no  malarial  organisms  were  found,  although  the  blood  of  each 
patient  was  searched.  Careful  search  was  also  made  for  the  pyro plasma 
hominis  but  no  bodies  were  found  which  could  be  considered  to  resemble 
this  organism  except  a  few  objects  which  were  considered  to  be  artefacts 
or  evidences  of  vacuolization  in  the  red  blood  cells.  A  progressive  diminution 
in  the  number  of  the  red  cells  was  constantly  present  and  there  was  a  corre- 
sponding diminution  in  the  amount  of  haemoglobin.  Examination  of  the 
leucocytes  showed  a  constant  moderate  relative  increase  in  the  number  of 
the  large  mononuclear  cells;  this  is  the  case  in  malaria  and  is  said  to  occur 
also  in  Rocky  Mountain  spotted  fever. 

Treatment.  The  administration  of  quinine  appears  to  have  no  effect 
upon  the  disease  and  seems  to  increase  the  discomfort  of  the  patient,  but 
arsenic,  given  by* hypodermatic  injection,  is  believed  to  control  the  paroxysms 
and  exert  a  curative  action  upon  the  infection.  The  arsenic  injections  may 
be  followed  by  a  burning  sensation  and  to  obviate  this  the  addition  of 
cocaine  is  suggested.  Kieffer  suggests  the  following  formula:  Sodium  arsenate 
I  part,  cocaine  hydrochloride  4  parts,  water  100  parts.  Thorough  antiseptic 
precautions  are  necessary  to  prevent  abscess  formation.  The  dosage  is  from 
15  to  30  minims  (i.o  to  2.0)  twice  a  day.  During  convalescence  the  patient's 
anaemia  should  be  combated  by  means  of  arsenic  per  os  in  connection  with 
iron  and  other  tonics. 

TYPHUS  FEVER. 

Synonyms.  Jail,  Camp,  Ship,  Hospital,  Putrid  or  Spotted  Fever;  Black 
Death. 

Definition.  An  acute  infectious  disease  characterized  by  a  typical  skin 
eruption,  nervous  symptoms  and  a  high  temperature  terminating  usually 
by  crisis  in  about  two  weeks. 

.Etiology.  ^  Typhus,  while  comparatively  rare  during  the  past  few  decades, 
was  formerly  one  of  the  world's  greatest  scourges.     Its  gradual  disappearance 
is  undoubtedly  due  to  the  increased  attention  paid  to  sanitation  and  the 
education  of  the  masses  along  general  hygienic  lines. 
3 


34  THE    INFECTIOUS    DISEASES. 

The  disease  is  of  markedly  infectious  nature  but  up  to  the  present  its  specific 
cause  has  not  been  determined.  It  is  most  common  in  young  adults  but  no 
age  is  exempt.  Its  occurrence  is  favored  by  crowded  and  filthy  conditions, 
unhygienic  surroundings  and  mode  of  life,  poor  ventilation,  and  famine. 
As  these  factors  are  becoming  year  by  year  less  conspicuous  features  of  our 
civilization  there  is  every  reason  to  hope  that  the  disease  will  ultimately  dis- 
appear from  the  earth. 

Isolated  cases  at  times  have  occurred,  but  despite  this  evidence  and  the 
fact  that  Murchison  considered  the  spontaneous  origin  as  possible,  it  is  not 
to  be  regarded  as  a  probability  in  the  light  of  present  day  knowledge. 

While  the  nature  of  the  contagion  is  unknown  it  is  recognized  that  it  is  of 
easv  acquirement  and  difficult  of  destruction.  It  seems  to  be  transmitted 
through  the  atmosphere  and  to  be  given  off  from  the  patient's  body.  Con- 
sequently it  is  communicable  from  one  person  to  another  and  through  furniture, 
bedding,  clothing,  etc.,  to  which  the  poison  of  the  disease  clings  for  long  periods. 
It  is  said  that  the  contagium  cannot  pass  through  the  air  from  hospitals  or 
other  structures  in  which  patients  suffering  from  the  disease  are  confined,  to 
dwellings  in  the  vicinity.  To  acquire  the  infection  intimate  and  fairly  con- 
tinuous association  with  the  patient  seems  to  be  necessary,  consequently  nurses 
are  much  more  frequently  affected  than  physicians  who  are  with  the  sufferer 
for  but  a  few  moments  each  day,  unless  indeed,  these  latter  are  in  attendance 
upon  a  typhus  hospital  or  ward. 

It  has  been  thought  that  the  contagium  is  given  off  from  the  skin  and  in 
the  expired  air;  it  may,  however,  be  in  all  the  body  excretions  and  discharges 
for  anything  that  is  certainly  known  to  the  contrary. 

Pathology.  There  are  no  characteristic  post  mortem  lesions.  The 
tissues  show  the  changes  which  always  accompany  acute  febrile  disease  of 
severe  type.  The  petechial  eruption  persists  after  death,  in  contradistinction 
to  that  of  enteric  fever,  and  bed  sores  may  be  present;  the  blood  is  dark  and 
fluid.  The  spleen  and  lymph  glands  are  enlarged  and  soft,  the  kidneys  and 
liver  may  be  increased  in  size.  The  tissues,  including  the  muscles,  and 
particularly  that  of  the  heart,  and  organs  are  in  a  condition  of  acute  degen- 
eration (cloudy  swelling).  There  is  no  intestinal  ulceration;  the  lungs  are 
frequently  the  seat  of  hypostatic  congestion  and  there  may  be  evidences  of 
bronchial  inflammation. 

Symptoms.  The  incubation  is  from  lo  to  12  days;  the  invasion  is 
usually  sudden  but  general  malaise  may  occur  before  this  event  takes  place. 
The  invasion  is  marked  by  one  or  more  chills  followed  by  fever  and  headache 
and  severe  bodily  pain,  especially  in  the  back.  After  the  initial  chill  the  tem- 
perature rises  rapidly  and  reaches  its  maximum  (104°  to  106°  F. — 40°  to  41.1° 
C.)  from  the  fourth  to  the  seventh  day.  The  patient  is  greatly  prostrated,  his 
tongue  is  coated  and  soon  becomes  dry,  nausea  and  vomiting  are  commonly 


TYPHUS    FEVER. 


35 


present,  the  eyes  are  suffused  and  the  expression  is  apathetic.  Bronchitis  is 
frequent.     The  bowels  are  usually  constipated. 

After  reaching  its  maximum  at  the  end  of  the  first  week,  the  fever  continues 
with  slight  morning  remissions  for  from  12  to  14  days.  At  the  end  of  this 
period  it  usually  begins  to  fall  by  crisis  and  may  drop  to  a  subnormal  level 
within  24  hours.  Death  in  severe  infections  may  be  preceded  by  a  tempera- 
ture of  108°  to  109°  F.  (42.2°  to  42.7°  C.). 

The  pulse  is  at  first  rapid  and  full  but  soon  becomes  weak  and  perhaps 
dicrotic  as  the  disease  progresses;  the  first  sound  of  the  heart  may  be  indis- 
tinct and  a  systolic  apical  murmur  may  be  present. 

The  respirations  are  rapid,  their  rate  often  being  further  increased  by 


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pulmonary  congestion,  bronchitis  or  a  co-existent  broncho-pneumonia  which 
may  be  followed  by  pulmonary  gangrene. 

The  urine  is  scanty  and  high  colored  and  frequently  contains  albumin 
and  casts. 

There  may  be  a  slight  increase  in  the  number  of  the  leucocytes,  the  opposite 
of  this  condition  obtaining  in  enteric  fever. 

The  eruption  is  constant  and  appears  on  the  third  to  the  fifth  day;  its  evolu- 
tion is  rapid.  It  presents  itself  first  upon  the  chest  and  abdomen  and,  quickly 
spreading  to  the  limbs  and  face,  involves  the  whole  body  within  two  or  three 
days.  The  rash  consists  of  two  elements:  a  dark  mottling  of  the  skin  char- 
acterized by  blotches  of  light  or  dark  purple;  these  may  be  rendered  lighter 


36  THE    INFECTIOUS    DISEASES, 

in  color  by  pressure  and  at  times  become  the  seat  of  subcutaneous  haemor- 
rhage; and  a  slightly  raised  petechial  eruption.  This  is  pinkish  in  color  and 
resembles  the  rash  of  enteric  fever,  disappearing  at  first  on  pressure  but 
later  persisting;  these  spots  also  are  haemorrhagic  and,  like  the  mottling, 
persist  post  mortem.  After  the  eruption,  which  lasts  from  7  to  10  days,  has 
disappeared  desquamation  usually  takes  place.  Children,  in  whom  the 
disease  is  seldom  fatal,  may  show  no  rash  whatever,  or  the  skin  may  be  covered 
by  an  eruption  not  unlike  that  of  measles. 

During  the  second  week  all  the  symptoms  become  more  marked.  The 
prostration  is  severe,  and  delirium,  changing  into  stupor  with  subsultus  tendi- 
num,  nystagmus  and  even  coma  vigil,  develops.  The  tongue  is  cracked  and 
dry,  the  teeth  are  covered  with  sordes,  the  temperature  is  persistently  high, 
the  pulse  rapid,  weak  and  perhaps  dicrotic,  the  respiration  is  accelerated 
and  the  patient  may  die  exhausted  by  the  infection.  In  the  event  of  his  recovery 
the  temperature  rapidly  falls  by  crisis  and  a  deep  sleep  occurs  from  which 
the  patient  awakes  greatly  improved,  the  mental  and  all  other  symptoms 
being  in  a  much  ameliorated  condition.  The  convalescence  now  progresses 
unless  a  relapse,  which  rarely  takes  place,  occurs. 

Variations  in  the  course  of  the  disease  may  be  observed.  Both  malignant 
forms,  in  which  death  supervenes  within  a  few  days,  and  mild  types  with 
only  slight  rise  in  temperature  and  other  insignificant  symptoms,  have  been 
described. 

Complications.  Of  these  broncho-pneumonia  is  the  most  frequent.  Gan- 
grene of  the  extremities,  paralysis  and  septic  infections,  such  as  subcutaneous 
abscesses,  parotitis  and  arthritis,  may  occur.  Noma  has  been  observed  in 
children. 

The  diagnosis  in  epidemics  is  easily  made  but  isolated  cases  may  be  mis- 
taken for  enteric  fever,  from  which  typhus  fever  may  be  differentiated  by  its 
more  rapid  initial  rise  in  temperature  and  otherwise  more  sudden  invasion, 
by  its  eruption  and  the  absence  of  Widal  reaction.  In  maUgnant  smallpox 
the  more  common  occurrence  of  haemorrhages  is  an  aid  in  differentiation. 
Epidemic  cerebrospinal  meningitis  at  its  onset  may  closely  resemble  typhus 
fever  but  after  a  few  days  the  diagnosis  is  usually  clear,  and  malignant  measles 
may  be  differentiated  by  the  accompanying  conjunctivitis  and  coryza  and 
the  fact  that  other  cases  of  measles  are  in  the  vicinity.  The  eruption  of 
measles  is  of  brighter  red,  presents  itself  first  on  the  face  and  is  likely  to  be 
crescentic  in  form. 

The  prognosis  varies  in  different  epidemics  ranging  at  times  as  high 
as  50  percent.,  the  usual  figures  are,  however,  from  12  to  20  percent.  In 
children  the  disease  is  seldom  fatal. 

Treatment.  Patients  suffering  from  tj^hus  fever  should  be  strictly 
isolated,  preferably  in  tents  where  the  free  ventilation  not  only  exerts  a  favor- 


MALTA    FEVER.  37 

able  efifect  upon  the  patient  but  renders  the  physicians  and  attendants  less 
likely  to  contract  the  disease.  The  fever  should  be  controlled  by  the  hydro- 
therapeutic  measures  employed  in  enteric  fever.  By  these  means  not  only 
is  the  temperature  lowered  but  a  favorable  influence  is  exerted  upon  the 
nervous  system.  Coal  tar  antipyretics  should  not  be  relied  upon  although 
they  may  be  occasionally  prescribed  in  connection  v^^ith  other  antipyretic  treat- 
ment. Their  weakening  effect  upon  the  heart  should  never  be  lost  sight  of, 
and  if  given,  these  drugs  should  be  administered  in  connection  with  stimu- 
lants which  shall  counteract  this  action.  Heart  stimvilants  are  indicated  early 
in  the  disease  and  of  these  alcohol  in  the  form  of  whiskey  or  brandy  is  to  be 
preferred;  digitaUs  and  strychnine  are  also  useful  in  this  connection.  Quinine 
is  strongly  recommended.  Attacks  of  cardiac  failure  should  be  combated  by 
the  hypodermatic  administration  of  aether  and  camphor  and  the  general 
treatment  of  symptoms  is  practically  identical  with  that  indicated  in  enteric 
fever.  The  bowels  should  be  kept  freely  open  from  the  onset  of  the  disease, 
it  being  usual,  when  seeing  the  patient  for  the  first  time,  to  prescribe  a  course 
of  calomel  in  fractional  doses  to  be  followed  by  a  saline  laxative.  ^  The  specific 
treatment  by  means  of  the  sulphocarbolates,  phenol  and  other  antiseptics  is 
probably  useless. 

In  the  treatment  of  this  disease  the  one  fact  to  be  kept  in  mind  is  that 
suflacient  stimulation  is  necessary  to  counteract  the  continued  tendency  to 
heart  weakness.  In  order  to  control  this  symptom  the  dosage  should  be 
regulated  in  accordance  with  the  patient's  condition.  In  markedly  asthenic 
states  the  hourly  administration  of  as  much  as  an  ounce  (30.0)  or  more  of 
whiskey  may  be  necessary. 

The  diet  should  be  entirely  of  fluids  during  the  febrile  stage,  milk  either 
plain  or  in  the  form  of  punch  with  egg  and  brandy,  nourishing  soups  and 
the  like  should  be  frequently  given.  As  convalescence  becomes  established 
soft  solids  and  a  gradual  return  to  ordinary  diet  may  be  allowed.  (See  diet 
of  enteric  fever,  pp.  16  and  17.) 

When  the  disease  is  treated  in  hospital  wards  or  private  dwellings  the 
most  thorough  ventilation  must  be  insisted  upon. 

During  the  coiurse  of  the  disease  the  excreta  and  all  articles  which  come 
into  contact  with  the  patient  should  be  disinfected  and  if  possible  destroyed. 
After  recovery  the  patient's  room  and  its  contents  must  be  thoroughly  fumi- 
gated. 

MALTA  FEVER. 

Synonyms.  Mediterranean  Fever;  Neapolitan  Fever;  Rock  Fever;  Undu- 
lant  Fever. 

Definition.  An  acute  infectious  disease  typified  by  an  irregular  tem- 
perature, profuse  sweats,  diffuse  pains  and  a  tendency  to  relapse. 


38  THE    INFECTIOUS    DISEASES. 

etiology.  This  disease  prevails  at  Malta  and  in  other  countries  whose 
shores  skirt  the  Mediterranean  Sea.  While  infrequent  in  other  regions,  it 
has  been  observed  in  the  West  and  East  Indies,  in  China  and  the  Philippines. 
One  or  two  instances  have  made  their  appearance  in  England  but  none  has 
ever  originated  in  the  United  States.  Malta  fever  attacks  young  adults  most 
frequently  and  prevails  chiefly  in  the  summer;  its  occurrence  is  favored  by 
unsanitary  conditions. 

The  specific  cause  of  this  affection  is  the  micrococcus  melttensis .  This 
organism  is  found  in  the  spleen  in  all  instances  of  the  disease  which  have 
come  to  autopsy  but  as  yet  has  not  been  isolated  from  the  blood.  When 
inoculated  into  monkeys  a  similar  disease  to  that  occurring  in  human  beings 
is  produced  and  the  micrococcus  may  be  isolated  from  the  tissues  of  the 
infected  animals.  The  organism  probably  enters  the  body  either  upon  the 
inspired  air  or  in  drinking  water;  in  one  instance  the  infection  has  taken  place 
through  the  conjunctiva.  It  has  been  shown  that  the  blood  of  patients  suffer- 
ing from  Malta  fever  causes  agglutination  of  pure  cultures  of  the  bacillus. 

Pathology.  No  definitely  characteristic  lesions  are  found  in  patients 
dying  of  this  disease.  It  has  been  stated  that  the  spleen  is  enlarged  and  that 
other  typical  lesions  of  enteric  fever  are  present. 

Symptoms.  The  incubation  period  is  from  a  few  days  to  three  or  four 
weeks.  The  invasion  of  the  disease  is  gradual,  without  chill  or  marked  rise 
in  temperature,  but  is  accompanied  by  malaise,  headache,  restlessness  and 
anorexia.  These  symptoms  persist  from  one  to  three  weeks  when  the  tem- 
perature falls  and  remains  normal  for  two  or  three  days,  then  it  rises  once 
more,  is  accompanied  by  chills,  associated  with  which  is  the  return  of  the 
other  symptoms  previously  mentioned.  This  relapse  lasts  a  month  or  six 
weeks  when  a  second  remission  takes  place.  This  may  last  from  one  to  two 
weeks  and  is  succeeded  by  a  second  relapse  which  is  accompanied  by  more 
marked  symptoms  than  the  first,  and  in  addition,  others,  such  as  sweats,  joint 
pains,  effusions,  constipation,  inflammations  of  the  fibrous  tissues,  and  orchitis; 
following  this  is  a  third  remission,  after  which  in  turn,  another  relapse  appears, 
characterized  by  the  symptoms  of  those  preceding,  with  high  fever,  night 
sweats  and  severe  pains.     The  spleen  is  as  a  rule  enlarged  and  may  be  tender. 

The  characteristic  features  of  this  disease  consist  in  the  recurrence  of 
rises  of  temperature  lasting  from  one  to  three  weeks  and  separated  by  afebrile 
intervals  lasting  a  few  or  more  days.  The  relapses  may  recur  for  two  or  three 
years  but  the  usual  length  of  the  disease  is  three  or  four  months.  The  fever, 
pain  and  other  symptoms,  if  long  continued,  must  necessarily  exert  an  exhaust- 
ing effect  on  the  patient  which  may  prove  fatal.  Cardiac  and  pulmonary 
complications  may  augment  the  severity  of  the  disease  and  become  factors 
in  its  fatal  outcome. 

Variations  in  the  type  of  Malta  fever  occur,  a  malignant  variety,  which 


RELAPSING    FEVER.  39 

may  result  fatally  within  one  or  two  weeks  and  a  mild  form  with  few  symp- 
toms save  an  evening  rise  of  temperature,  having  been  described.  One  attack 
of  the  disease  is  likely  to  confer  immunity,  for  several  years  at  least. 

The  dififerential  diagnosis  from  enteric  fever  may  be  made  by  means  of 
agglutination  tests. 

The  prognosis  is  usually  favorable,  the  mortality  being  put  at  about  2  percent. 
by  most  observers. 

Treatment.  No  drug  has  a  specific  effect  upon  this  disease.  Attempts 
have  been  made  to  elaborate  an  antitoxin  and  at  least  one  patient  seems 
to  have  been  successfully  treated  by  this  means. 

The  bowels  should  be  kept  open  and  the  kidneys  active.  Hydrotherapeutic 
measures,  particularly  sponging  with  cool  water,  should  be  employed  to 
control  the  temperature  and  the  symptoms  should  be  relieved  by  the  methods 
applicable  in  like  conditions,  such  as  those  which  occur  in  enteric  fever. 

Recently  it  has  been  suggested  that  an  exclusively  milk  diet  is  unnecessary 
unless  the  temperature  runs  above  103°  F.  (39.5°  C).  To  patients  whose 
evening  temperature  does  not  rise  above  this  point  easily  digestible  solids, 
such  as  the  cereals,  eggs  and  bread,  are  allowed  in  addition  to  milk  and  broths. 
Even  fish  and  meat  are  permitted  if  no  ill-effects  result  from  the  lighter  solids. 

During  convalescence  the  patient's  exhaustion  and  anaemia  should  receive 
tonic  treatment,  he  should  keep  in  the  fresh  air  as  much  as  possible  and  his 
emaciation  may  derive  benefit  from  inunctions  of  codliver  oil  and  lanolin. 
A  change  of  climate,  when  the  patient  is  able  to  travel,  is  distinctly  indicated. 

RELAPSING  FEVER. 

Synonyms.  Famine  Fever;  Recurrent  Typhus;  Spirillum  Fever;  Seven 
Day  Fever. 

Definition.  A  specific  acute  infectious  disease  characterized  by  a  febrile 
movement  lasting  six  or  seven  days,  followed  by  an  afebrile  interval  of  about 
a  week,  after  which  the  febrile  paroxysm  recurs  and  may  be  repeated  three  or 
four  times. 

Etiology.  The  most  favorable  conditions  for  the  development  of  this 
disease  are  those  of  over-crowding,  famine  and  filth,  just  as  is  the  case  with 
typhus  fever.  It  is  common  in  East  India  and  has  prevailed  at  times  in 
Europe  and  the  United  States.  It  has  not  been  observed,  except  in  isolated 
instances,  in  this  country,  however,  since  1869.  Age  and  sex  seem  to  have  no 
influence  upon  its  incidence. 

The  specific  cause  of  the  infection  is  the  spirochaeta  of  Obermeier  which 
was  discovered  in  1873.  This  organism  is  a  spiral  shaped  bacterium  in 
length  from  three  to  six  times  the  diameter  of  a  red  blood  cell.  It  is  found 
in  the  blood,  but  only  during  the  febrile  stage;  it  has  never  been  demonstrated 


40 


THE    INFECTIOUS    DISEASES. 


in  the  secretions  or  excretions.  The  disease  has  been  produced  in  human 
beings  and  monkeys  by  the  injection  of  blood  from  a  patient  during  the 
febrile  stage.  Formerly  it  was  believed  that  recurrent  fever  was  transmitted 
by  means  of  fomites  but  the  more  recent  studies  of  Tictin  tend  to  confirm 
the  idea  that  it  may  be  carried  by  means  of  suctorial  insects  such  as  bed 
buCTS,  since  blood  taken  from  one  of  these  insects  which  had  bitten  an  infected 
individual  has  produced  the  disease  when  injected  into  apes. 

One  attack  of  the  disease  does  not  confer  immunity. 

Pathology.  No  typical  morbid  changes  are  observed  after  death  from 
this  disease.  During  the  febrile  movement,  however,  the  spleen  is  enlarged, 
and   the   viscera    are  swollen    and  are   the  seat  of  an  acute  degeneration 


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The  skin  may  be  jaundiced  and  ecchymotic  and  the  bone  marrow  is  in  a 
state  of  hyperplasia. 

Symptoms.  The  incubation  period  is  usually  about  one  week  although 
the  symptoms  in  certain  instances  may  appear  within  a  day  or  two  after 
infection.  The  onset  is  sudden  with  a  chill  followed  by  fever,  malaise  and 
general  pains;  nausea  and  vomiting  may  occur  and  sweating  is  common. 
The  temperature  rises  rapidly  and  may  reach  104°  F.  (40°  C.)  upon  the 
first  day.     In  children  the  disease  may  be  ushered  in  by  a  convulsion. 

The  pulse  is  rapid  (no  to  130).  Jaundice  is  not  infrequent  and  severe 
nausea  and  vomiting  and  cerebral  symptoms  may  be  observed.     The  spleen 


RELAPSING    FEVER.  41 

is  enlarged  and,  rarely,  may  rupture.  There  may  be  herpetic  vesicles  upon 
the  lips  and  petechiae  or  motthng  of  the  skin  may  be  noted. 

The  liver  may  be  palpable.  During  the  paroxysm  the  blood  contains  the 
spirochaetae.     The  leucocytes  are  often  increased  in  number. 

After  the  fever  has  lasted  about  seven  days  it  falls  by  crisis  in  a  few  hours 
to  normal  or  below  this  point  and  with  this  fall  there  is  profuse  perspiration, 
sometimes  diarrhoea  or  nose-bleed,  and  a  general  amelioration  of  the  symp- 
toms. Within  a  few  hours,  or  at  most  a  day  or  two,  the  patient  is  apparently 
well.  The  crisis  may  occur  as  early  as  the  third  day  or  as  late  as  the 
tenth.     In  the  aged  or  in  weak  individuals  it  may  be  associated  with  collapse. 

After  about  one  week  and  usually  on  the  14th  day  from  the  invasion,  the 
paroxvsm  is  repeated,  being  ushered  in  by  one  or  more  chills,  the  fever  recurs 
and  the  other  symptoms  reappear.  The  relapse  is,  as  a  rule,  shorter  than 
the  primary  paroxysm  and  is  terminated  by  crisis  in  the  same  manner.  After 
another  afebrile  interval  there  may  be  a  second,  and  following  this,  a  third 
relapse.  Rarely  has  a  fourth  been  observed.  Each  succeeding  relapse  is 
shorter  than  its  predecessor.  At  times  there  is  no  relapse,  the  patient  recover- 
ing after  the  first  crisis.  Convalescence,  while  usually  rapid,  may  be  much 
protracted  in  patients  who  have  been  weakened  by  severe  types  of  the  infec- 
tion. 

Complications  such  as  nephritis  with  haematuria,  hsematemesis,  rupture 
and  infarct  of  the  spleen,  paralyses  and  obstinate  ophthalmia  may  occur. 
In  females,  if    pregnant,  abortion  usually  takes  place. 

The  disease  is  not  very  fatal;  death,  however,  may  take  place  during  the 
paroxysm  in  aged  and  feeble  patients  or  as  a  result  of  a  complication. 

The  differential  diagnosis  from  enteric  fever  and  from  malaria,  the  two 
diseases  with  which  relapsing  fever  is  most  likely  to  be  confounded,  may  be 
made  by  examination  of  the  blood.  Specimens  should  be  taken  from  a 
finger-prick,  spread  thinly  and  may  be  examined  fresh  or  stained  with  various 
aniline  colors. 

Treatment.  No  drug  has  yet  been  found  which  exerts  any  influence  upon 
this  disease ;  a  serum  has,  however,  been  elaborated  from  the  blood  of  infected 
horses,  the  use  of  which  has  been  attended  with  good  results.  The  treat- 
ment in  other  respects  is  symptomatic.  The  patient  should  be  kept  in 
bed  during  the  paroxysms  and  should  be  exposed  as  little  as  possible  during 
the  intervals,  lest  a  relapse  be  induced.  At  the  onset  a  mercurial  purge  should 
be  given  and  followed  by  a  saline.  Throughout  the  disease  the  bowels 
should  be  kept  open  and  the  kidneys  active.  The  temperature  should  be 
controlled  by  hydrotherapeutic  measures  and  the  pains  by  small  doses  of  the 
coal  tar  analgesics.  Patients  in  whom  the  pain  is  marked  and  distressing 
may  be  allowed  small  quantities  of  powder  of  ipecac  and  opium  or  morphine. 
In  enfeebled  patients  the  early  exhibition  of  stimulants,  especially  alcohol 


42  THE    INFECTIOUS    DISEASES. 

and  strychnine,  is  necessary.  Emesis  may  be  controlled  by  pellets  of  cracked 
ice,  sips  of  iced  champagne,  small  doses  of  cocaine  or  the  hypodermatic 
administration  of  morphine  should  this  become  unavoidable. 

The  diet  during  the  febrile  paroxysm  should  be  entirely  of  fluids,  while 
during  the  remissions  easily  digestible  and  nourishing  solids  may  be  allowed. 
During  the  progress  of  convalescence  the  patient  should  receive  general 
tonic  treatment. 

YELLOW  FEVER. 

Synonyms.  Febris  Flava;  Bilious  Remittent  Fever;  Typhus  Icteroides; 
Typhus  Tropicus. 

Definition.  Yellow  fever  is  an  acute  infectious  disease  characterized  by 
a  febrile  paroxysm  which  is  followed  by  a  short  remission  which  in  turn  is 
succeeded  by  a  relapse.  It  is  often  accompanied  by  jaundice  and  a  tendency 
to  haemorrhages,  especially  into  the  stomach. 

.Etiology.  This  disease  prevails  endemically  in  certain  tropical  cities 
and,  according  to  Guiteras,  these  zones  of  infection  may  be  recognized:  o. 
The  focal  zone,  from  which  yellow  fever  is  never  absent,  including  Vera  Cruz, 
Rio  de  Janeiro  and  other  Spanish  American  ports,  h.  The  perifocal  zone 
or  region  of  periodic  epidemics,  which  includes  the  tropical  ports  of  the 
Atlantic  coasts  of  America  and  Africa,  c.  The  zone  of  accidental  epidemics, 
between  the  parallels  of  45°  north  and  35°  south  latitude. 

Yellow  fever  is  seldom  seen  far  from  the  sea-coast  or  at  an  altitude  greater 
than  1000  feet.  It  is  a  disease  of  the  summer  months,  disappearing  with  the 
incidence  of  frost,  and  is  prone  to  attack  cities,  especially  in  their  most  thickly 
populated  and  unsanitary  districts.  Males  seem  to  be  more  subject  to  infec- 
tion than  females,  and  the  disease  attacks  all  ages  except  young  infants. 
Negroes  and  mixed  races  seem  to  be  less  prone  to  the  affection  than  whites, 
possibly  because,  during  their  continued  residence  in  regions  where  the  disease 
is  endemic,  they  may  have  suffered  from  an  abortive  and  unrecognized  type 
of  infection.     Immunity  is  usually  but  not  always  conferred  by  one  attack. 

The  specific  cause  of  yellow  fever,  which  is  in  all  probability  a  micro-organism, 
has  not  yet  been  isolated;  several  observers  have  described  organisms  which 
they  have  considered  to  be  the  specific  germ  but  their  observations  have  not 
been  confirmed. 

The  chief,  and  very  probably  the  only,  mode  of  transmission  of  yellow 
fever  is  through  the  bite  of  a  species  of  mosquito,  the  stegomyia  fasciata. 
Rigid  experiments  have  shown  that  the  disease  is  not  conveyed  by  means  of 
fomites.  That  the  infection  may  be  transmitted  to  a  non-immune  by  injec- 
tion of  blood  drawn  from  yellow  fever  patients  has  also  been  proven. 

Pathology.     The  skin  is  of  icteroid  hue,  although  jaundice  may  not  have 


YELLOW    FEVER.  43 

been  evident  ante  mortem,  and  subcutaneous  extravasations  of  blood  may  be 
present.  The  blood-serum  contains  haemoglobin  resulting  from  the  destruc- 
tion of  the  red  blood  cells.  The  heart  may  be  the  seat  of  fatty  degeneration. 
The  liver  is  enlarged  and  congested,  later  it  undergoes  fatty  changes  and  is 
yellowish-brown  in  color.  Spots  of  necrosis  are  usually  present.  The 
kidneys  are  enlarged,  congested  and  the  seat  of  acute  inflammation.  Areas 
of  necrosis  may  occur  in  these  organs  as  well  as  in  the  liver.  The  gastric 
mucosa  is  congested  and  swollen,  there  may  be  submucous  haemorrhages 
and  the  organ  may  contain  blood-serum  and  degenerated  blood  pigment  (black 
vomit).  There  may  be  general  enlargement  of  the  lymph  nodes,  particularly 
those  of  the  peritonaeum,  of  the  neck  and  axillae.  Changes  characteristic  of 
yellow  fever  alone  have  never  been  noted. 

Symptoms.  The  incubation  period  is  from  three  to  four  days,  rarely 
over  five  days.  Prodromata  are  rare,  the  invasion  being  usually  sudden 
with  chilly  feelings,  or  convulsions  in  the  case  of  children,  followed  by  head- 
ache, general  pains,  prostration  and  fever.  The  onset  usually  takes  place 
between  midnight  and  dawn.  The  temperature  soon  reaches  102°  to  105°  F. 
(38.9°  to  40.5°  C).  The  face  is  flushed,  the  eyes  are  injected  and  watery  and 
photophobia  is  present.  The  pulse  is  weak  and  at  first  rapid  in  proportion 
to  the  height  of  the  temperature,  after  a  day  or  two,  even  though  the  fever  is 
higher  than  before,  the  pulse  rate  begins  to  decrease  and  gradually  continues 
to  do  so  until  it  may  become  slower  than  normal  before  the  fever  declines. 
This  lack  of  proportion  between  the  pulse  rate  and  the  height  of  the  tem- 
perature is  characteristic  of  this  disease  and  is  an  important  diagnostic  point. 

The  skin  is  hot  and  dry,  the  tongue  is  red  and  cracked  and  the  throat  and 
gums  may  be  sore.  Slight  jaundice  may  appear  early  in  the  disease.  Nausea 
and  vomiting  may  appear  at  the  invasion  but  are  more  likely  not  to  occur 
until  the  second  or  third  day.  In  severe  infections  the  vomitus  may  be  of 
coffee-ground  material,  tar-like  or  even  of  unchanged  blood,  while  in  milder 
forms  it  consists  merely  of  blood  particles,  mucus  and  bile.  The  bowels  are 
usually  constipated  but  the  stools  are  not  clay-colored.  With  slight  varia- 
tions in  temperature  this,  the  first  stage  of  the  disease,  lasts  three  or  four  days 
and  is  terminated  by  the  return  of  the  temperature  by  lysis  to  normal. 

At  this  time  the  second  stage  or  stage  of  calm  begins,  the  symptoms  dis- 
appear and  in  mild  cases  convalescence  becomes  established.  In  the  severe 
infections  this  stage,  after  lasting  from  a  few  hours  to  a  day  or  two,  merges 
into  the  third  stage. 

In  this  stage,  although  rarely  there  may  be  no  fever,  the  temperature  rises 
again  while  the  pulse  rate  may  decrease  to  even  as  low  as  60.  The  jaundice 
becomes  more  pronounced,  the  tongue  is  dry,  brown  and  cracked,  and  nausea 
and  vomiting  return.  Haematemesis  with  abdominal  pain  is  frequent,  there 
may  be  tarry  stools  and  haemorrhages  from  the  nose,  gums,  uterus,  kidneys 


44 


THE    INFECTIOUS    DISEASES. 


and  into  the  skin.  There  may  be  suppression  of  urine  with  death  from  uraemia, 
or  the  patient  may  grow  progressively  weaker  and  die  of  the  profound  toxaemia, 
the  fever  remaining  elevated  until  this  has  occurred.  In  more  favorable  in- 
stances after  a  secondary  fever  of  two  or  three  days,  the  temperature  falls 
by  lysis,  the  symptoms  ameliorate  and  the  patient  goes  on  to  a  protracted  con- 
valescence during  which  jaundice  may  be  persistent. 

Albuminuria  is  a  feature  of  this  disease,  appearing  in  mild  infections  even  on 


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Fig.  4. — Clinical  chart  of  yellow  fever  showing  the  pulse  typically  slow  in  comparison 
to  the  height  of  the  temperature. 

the  second  or  third  day.  It  may  be  merely  transitory  but  in  severe  infections 
it  is  present  in  large  amounts  and  is  accompanied  by  casts.  At  times  the 
nephritis  may  result  in  anuria  and  death  from  ura^mic  poisoning. 

Relapses  sometimes  take  place;  complications  are  not  very  common;  such 
sequelae  as  parotitis  and  multiple  abscesses  have  been  observed. 

The  diagnosis  of  the  disease  may  at  times  be  difficult.  Malarial  fever 
of  the  remittent  type  may  be  differentiated  from  yellow  fever  by  the  earlier 
incidence  of  the  remission,  the  longer  duration  of  the  chill  and  the  presence 


YELLOW    FEVER.  45 

in  the  blood  of  the  malarial  parasite  in  the  former  disease.  In  the  differentiation 
the  three  salient  characteristics  of  yellow  fever  are  aids,  these  being  the  typical 
facial  expression,  slow  pulse  and  early  occurrence  of  albuminuria.  These 
points  are  serviceable  in  the  separation  of  the  disease  from  dengue  as  are  also 
the  haemorrhages  and  the  early  occurrence  of  jaundice  in  yellow  fever  in  con- 
tradistinction to  the  absence  of  the  former  and  the  possible  later  incidence 
of  the  latter  in  dengue. 

The  prognosis  in  yellow  fever  is  grave,  the  severer  forms  of  the  infection 
being  particularly  fatal.  In  weak,  poorly-noiu-ished  and  alcoholic  subjects 
the  chances  of  recovery  are  less  than  in  those  in  whom  the  opposite  conditions 
obtain.  Of  patients  who  exhibit  the  "black  vomit"  by  no  means  all  die, 
but  those  profoundly  poisoned  and  in  whom  mental  and  kidney  symptoms 
occur  seldom  recover. 

The  prevention  of  yellow  fever  consists  in  the  guarding  of  patients  suffering 
from  the  disease  from  the  bites  of  mosquitoes,  in  the  obstruction  of  ways  of 
ingress  of  the  mosquito  to  the  house,  of  the  destruction  of  these  insects  within 
dwellings  and  of  the  employment  of  means  with  a  view  to  prevent  their  prop- 
agation. How  effectually  the  disease  may  be  prevented  is  evidenced  by  its 
rarity  in  Havana,  where  it  formerly  prevailed  largely,  since  proper  steps  have 
been  taken  in  prophylaxis.  Mosquitoes  in  dwellings  may  be  destroyed  by 
means  of  sulphur  fumigation  and  may  be  prevented  from  entering  by  means 
of  screens.  Patients  suffering  from  the  disease  should  be  surrounded  by 
netting.  Although  the  most  recent  observers  believe  that  yellow  fever  is  not 
transmitted  in  any  other  way  than  by  the  mosquito  and  that  disinfection  of 
clothing,  bedding  and  the  like  is  unnecessary,  it  may  be  wise  to  employ  the 
usual  disinfection  methods  of  the  sick-room  and  its  contents  after  the  patient's 
recovery. 

Preventive  inoculation  has  not  been  employed  with  success. 

Treatment.  The  patient  should  be  isolated  and  screened.  He  must  be 
strictly  confined  to  bed  from  the  onset  and  should  be  moved  as  little  as  possible. 
The  bowels  and  bladder  must  be  evacuated  while  in  the  recumbent  position 
and,  should  it  be  impossible  to  urinate  under  these  circumstances,  catheter- 
ization must  be  undertaken.  All  body  and  bed  linen  must  be  kept  scrupu- 
lously clean  and  when  these  are  changed  the  utmost  care  not  to  disturb  the 
patient  to  the  least  degree  must  be  observed.  Food  and  medicines,  when 
taken  by  mouth,  should  be  given  by  means  of  a  spouted  cup  or  through  a 
tube,  so  that  the  head  need  not  be  raised. 

At  the  onset  of  the  disease  the  bowels  shoiild  be  opened  by  fractional  doses 
of  calomel  followed  by  a  saline  laxative;  here  magnesium,  in  the  form  of 
the  effervescing  citrate,  or  sodium  sulphate  is  to  be  preferred.  The  kidneys 
should  be  mildly  stimulated  by  one  of  the  alkaline  diuretics  and  the  skin 
kept  active  by  means  of  tepid  sponge  baths.     During  the  febrile  stages  it  is 


46  THE   INFECTIOUS   DISEASES. 

wise  to  feed  entirely  per  rectum  and  to  administer  medication  by  means  of 
this  channel  or  hypodermatically.  For  the  temperature  and  nervous  symp- 
toms hydrotherapeutic  measures  are  indicated.  Cool  sponging  is  perhaps 
best  and  the  baths  should  be  given  with  great  care  so  as  to  disturb  the  patient 
as  little  as  possible.  The  pain  may  be  relieved  by  means  of  small  doses 
— gr.  v  (0.33) — of  acetphenetidine  (phenacetine)  combined  with  caffeine 
sodio-benzoate  if  there  is  the  slightest  tendency  to  cardiac  weakness.  While 
most  authorities  advise  the  hypodermatic  administration  of  morphine  if 
the  pain  is  severe,  certain  observers,  whose  experience  of  the  treatment  of 
yellow  fever  has  been  considerable,  consider  this  drug  contraindicated  at 
all  stages  of  the  disease;  quinine  given  per  rectum — gr.  xx  (1.33) — is  useful 
in  this  affection.  Formerly  this  drug  was  extensively  employed  in  yellow 
fever  and  while  it  is  probable  that  it  exerts  no  specific  effect  its  administration 
does  no  harm.  Vomiting  is  difficult  of  control  and  should  be  treated  by 
pellets  of  cracked  ice.  Small  doses  of  cocaine — gr.  \  (0.016) — of  hydro- 
cyanic acid,  of  creosote  or  of  phenol  have  been  recommended  but  ice 
alone  usually  accomplishes  all  that  is  possible.  Hcemorrhage  may  be  com- 
bated by  the  hypodermatic  administration  of  ergot  or  by  means  of  calcium 
chloride,  gr.  xl  (2.66)  per  rectum.  The  latter  drug  is  said  to  cause  an  increased 
coagulability  of  the  blood.  Lead  acetate  and  iron  perchloride  have  been 
advocated  but  are  probably  better  omitted. 

During  the  course  of  the  disease  the  kidneys  and  the  circulatory  system 
may  be  stimulated  and  the  toxasmia  lessened  by  high  rectal  irrigations  of  hot 
— 110°  to  116°  F.  (43.5°  to  46.5°  C.) — normal  saline  solution.  Two  of  these 
may  be  given  daily  and  the  quantity  should  be  at  least  i  gallon  (4  litres). 
The  ursemic  symptoms  respond  very  favorably  to  this  means  of  treatment; 
here  also  hot  baths  and  packs  are  useful.  If  at  any  time  there  are  symptoms 
of  cardiac  weakness,  free  hypodermatic  stimulation  by  means  of  alcohol,  strych- 
nine, digitalis,  camphor  and  aether,  or  camphor  and  oil  are  indicated.  Collapse 
may  be  treated  by  this  means,  by  the  hypodermatic  or  intravenous  adminis- 
tration of  considerable  quantities  of  normal  salt  solution  and  by  enemata 
of  strong  black  coffee. 

During  the  stage  of  remission  the  patient's  strength  must  be  supported 
by  means  of  stimulants  and  tonics. 

The  following  treatment  of  the  disease  has  been  recommended.  Sodium 
bicarbonate  gr.  vii  ss  (0.5)  and  mercury  bichloride  gr.  ^L.  (o.ooi)  are  given 
dissolved  in  ice  water  every  one  or  two  hours,  depending  upon  the  severity  of 
the  infection;  the  sodium  bicarbonate  tends  to  lessen  the  excessive  acidity 
of  the  gastric  juice  and  urine  and,  by  rendering  the  latter  alkaline,  the  tendency 
to  nephritis  and  anuria  may  be  diminished.  At  the  invasion  the  patient  is 
given  a  hot  mustard  foot  bath  and  for  the  following  three  or  four  days  cool 
sponges  are  given,  an  ice  bag  is  applied  to  the  head  and  a  sinapism  to  the 


INFLUENZA.  47 

epigastric  and  lumbar  regions.  No  food  is  given  during  the  first  three  days 
of  the  disease. 

The  serum  treatment  of  yellow  fever,  although  the  subject  of  much  exper- 
imentation, has  as  yet  yielded  no  very  favorable  results. 

During  convalescence  the  patient  should  be  kept  in  bed  or  at  any  rate  until 
the  profound  prostration  which  is  a  feature  of  yellow  fever  has  disappeared 
and  the  heart  and  kidneys  have  returned  to  their  normal  action,  he  should 
be  kept  at  rest.  Tonics  such  as  iron,  strychnine  and  quinine  should  be  pre- 
scribed. 

The  food  during  the  febrile  stages  should  be  administered  wholly  per 
rectum,  nutrient  enemata  such  as  those  suitable  in  gastric  ulcer  being  indicated 
(see  p.  366);  during  the  remission  fluids  may  be  given  by  mouth  and,  after  con- 
valescence has  become  established,  the  greatest  caution  must  be  observed  in 
feeding.  No  solids  should  be  given  for  at  least  ten  days  after  the  symptoms 
have  subsided  and  too  large  quantities  at  a  time  must  be  avoided.  The 
first  foods  allowed  by  mouth  are  peptonized  milk,  milk,  milk  and  vichy, 
kumyss  or  matzoon,  one  drachm  (4.0)  every  half  hour,  later  beef  juice  may  be 
given,  then  the  whites  of  eggs,  the  proprietary  infant  foods,  broths  and  gruels. 
Gradually  the  various  semi-soHds,  junket,  cereals,  milk  toast,  etc.,  may  be 
added  until  finally  the  patient  is  able  to  tolerate  solid  diet. 

INFLUENZA. 

Synonyms.     Epidemic  Catarrhal  Fever;  Grip. 

Definition.  An  acute  infectious  disease,  generally  endemic  and  from 
time  to  time  occurring  in  widespread  epidemics,  characterized  by  catarrhal 
inflammations  of  the  various  mucous  membranes,  prostration  and  a  tendency 
to  involvement  of  the  nervous  system. 

.Etiology.  At  various  periods  of  the  world's  history  since  the  sixteenth 
century  widespread  epidemics  of  this  disease  have  occurred,  the  last  of  these 
in  1889,  when  within  a  year  it  had  prevailed  in  most  parts  of  the  civilized  world. 
Since  this  epidemic,  in  most  American  cities,  there  are  seen  yearly  a  number 
of  instances  of  epidemic  influenza.  Epidemics  remain  in  a  locality  from  one  to 
two  months  and  the  afi'ection  is  prone  to  attack  a  very  large  proportion  of  the 
population.  Epidemics  differ  greatly  in  severity  and  in  liability  to  com- 
plications. 

The  specific  factor  in  the  causation  of  this  disease  is  the  influenza  bacillus 
which  was  discovered  by  Pfeifler  in  1892.  It  occurs  in  great  numbers  in  the 
nasal,  tracheal  and  bronchial  secretions  of  patients  affected  and  may  be 
easily  demonstrated. 

Epidemic  influenza  is  markedly  contagious  and  rapid  in  its  spread,  and  occurs 
with  its  greatest  degree  of  severity  in  the  colder  seasons  of  the  year.     Unhy- 


48  THE    INFECTIOUS    DISEASES. 

gienic  surroundings  do  not  seem  to  affect  its  incidence;  it  attacks  all  ages 
and  both  sexes  and  those  who  have  suffered  from  one  infection  seem  more 
prone  than  others  to  a  second. 

Authorities  differ  as  to  the  portal  of  entry  of  the  contagium,  probably, 
however,  it  reaches  the  organism  upon  the  inspired  air  and  the  infection  takes 
place  through  the  respiratory  tract.  It  is  also  asserted  that  the  primary  lodg- 
ment of  the  bacillus  may  be  the  gastro-intestinal  tract  or  the  conjunctiva. 

Pathology.  This  disease  is  characterized  by  no  typical  lesions;  only  those 
due  to  the  complications  are  found  post  mortem.  In  the  abdominal  type 
of  the  infection  there  may  be  enlargement  of  the  solitary  and  agminated 
follicles  of  the  intestine. 

Symptoms.  The  incubation  period  is  from  one  to  three  or  four  days, 
although,  at  times,  the  interval  between  the  entrance  of  the  contagium  into  the 
body  and  the  manifestation  of  the  symptoms  may  be  longer. 

The  onset  is  usually  sudden  with  a  chill  followed  by  a  rise  in  temperature — 
ioi°  to  104°  F.  (38.4°  to  40°  C.) — severe  headache  and  marked  bodily  pains; 
nausea  and  vomiting,  together  with  the  other  symptoms  usual  at  the  beginning 
of  an  acute  infection,  and  very  pronounced  prostration  may  be  present.  The 
fever  lasts  from  two  to  six  days  and  may  be  of  remittent  or  intermittent  type; 
in  certain  instances  the  elevation  of  the  temperature  may  be  the  only  symptom 
and  rarely  the  patient  may  exhibit  a  continuously  high  temperature  lasting 
for  several  weeks  and  which  closely  resembles  that  of  enteric  fever;  the  pulse 
is  rapid  and  may,  in  severe  types  of  the  disease  and  in  the  aged,  become  feeble. 
During  the  course  of  the  disease  various  skin  eruptions,  erythematous  or  even 
purpuric,  may  appear  and  simple  pharyngitis  may  be  present.  As  the  tem- 
perature approaches  the  normal  at  the  termination  of  the  disease,  sweating 
may  occur  and  the  symptoms  gradually  subside. 

The  disease  manifests  itself  in  one  of  several  types  which  are  very  prone  to 
merge  into  one  another. 

a.  The  catarrhal  type  is  characterized  by  symptoms  referable  to  the  mucous 
membranes  of  the  respiratory  tract  and  conjunctivas.  At  the  onset  the  symp- 
toms of  coryza,  with  sneezing,  nasal  discharge,  a  feeling  of  fulness  in  the  head, 
sore  throat,  hoarseness  and  conjunctival  injection,  are  present.  In  the  milder 
instances  of  the  disease  there  may  be  no  further  symptoms,  but  more  often 
there  is  bronchial  inflammation,  with  cough,  at  first  dry,  later  with  muco- 
purulent and  sometimes  very  copious  expectoration;  rarely  the  sputum  is 
dark  and  blood-stained.     Various  pulmonary  complications  may  ensue. 

h.  The  nervous  type  begins  with  severe  headache,  pains  in  the  bones  and  joints 
and  extreme  depression  and  prostration;  rarely  there  may  be  convulsions. 
In  some  instances  there  are  symptoms  resembling  those  of  meningitis,  such  as 
photophobia,  hypersensitiveness  to  sounds,  pain  in  the  back  of  the  head  and 
stiffness  of  the  neck.     Delirium  may  be  present.     The  nervous  symptoms 


INFLUENZA.  49 

gradually  subside  after  a  few  days  but  during  convalescence  there  is  a  marked 
tendency  to  mental  depression  and  neuralgia  in  various  parts  of  the  body. 

c.  The  gastro-intestinal  type  is  evidenced  by  nausea  and  vomiting  at  the 
invasion,  or  abdominal  pain,  distention  and  diarrhoea;  the  symptoms  may  be 
so  severe  as  to  suggest  appendicitis  or  peritonitis.  Jaundice  and  splenic 
enlargement  may  be  present. 

Complications  and  sequelae.  Of  these  one  of  the  most  common  and 
serious  is  pneumonia  due  to  the  influenza  bacillus  alone  or  to  a  mixed 
infection.  It  is  rarely  if  ever  of  the  lobar  form,  usually  being  catarrhal  or 
lobular,  and  is  frequently  fatal.  Pleurisy  is  not  a  common  complication  but 
when  it  occurs  is  likely  to  become  purulent. 

Bronchiectases  may  occur.  Circulatory  complications  may  appear.  Peri- 
carditis is  rare;  less  so  is  endocarditis  which  may  be  of  malignant  type.  In  a 
few  instances  the  influenza  bacillus  has  been  grown  from  the  vegetations. 
Myocarditis  may  occur  and  functional  cardiac  disorders,  such  as  palpitation, 
irregular  heart  action,  bradycardia  and  tachycardia  are  frequently  met. 
Sudden  cardiac  failure  may  cause  death.  Thrombosis  and  phlebitis  have 
been  observed. 

Peritonitis,  cholecystitis  and  septicaemia  are  rare  sequels;  nephritis  and 
orchitis  have  been  noted. 

Complications  referable  to  the  nervous  system  are  not  infrequent  and 
among  them  may  be  mentioned  encephalitis,  meningitis — the  bacilli  having 
been  demonstrated  in  the  fluid  withdrawn  by  lumbar  puncture — cerebral 
abscess,  myelitis,  neuritis  of  various  types,  and  paralyses.  Mental  disorders 
such  as  melancholia  or  even  dementia  may  occur.  Optic  neuritis  and  iritis 
have  been  described;  otitis  media  and  dizziness,  due  to  affection  of  the  labyrinth, 
are  possible  consequences. 

It  is  of  the  utmost  importance  to  keep  in  mind  the  fact  that  an  attack  of 
influenza  is  very  prone  to  render  any  latent  disease  active  and  to  increase  the 
intensity  of  any  slight  organic  affection  that  may  be  present. 

The  diagnosis  of  influenza  during  an  epidemic  is  usually  easy  and  may  be 
confirmed  when  doubtful  by  the  detection  of  the  causative  bacillus  in  the 
mucous  discharges. 

The  prognosis  is  usually  good.  Death  may  take  place  from  the  complica- 
tions, particularly  from  pneumonia. 

Treatment.  The  prevention  consists  in  the  avoidance  of  exposure  to 
cold  and'  wet  during  epidemics  and  of  association  with  patients  suffering 
from  the  disease.  Isolation  of  patients  should  be  carried  out  whenever  prac- 
ticable and  the  sputum  and  nasal  discharges  should  be  disinfected  and  des- 
troyed. When  influenza  is  prevalent  it  is  well  to  practise  spraying  of  the 
oral  and  nasal  cavities  with  some  mild  antiseptic  such  as  liquor  antisepticus. 

So  long  as  we  are  ignorant  of  any  specific  agent  which  will  abort  an  attack 
4 


50  THE    INFECTIOUS    DISEASES. 

or  mitigate  the  severity  of  the  infection  we  must  formulate  a  treatment  for 
each  type  of  the  disease. 

In  treating  the  respiratory  form  of  epidemic  influenza  we  should  first 
bear  in  mind  the  fact  that  the  prostration,  fever  and  systemic  disturbance 
are  out  of  all  proportion  to  the  extent  or  severity  of  the  disease  as  evidenced 
by  physical  signs;  secondly,  that,  granted  a  moderate  involvement  of  respiratory 
area  or  even  a  disease  stationary  so  far  as  extent  of  tissue  is  involved,  this  is  no 
guarantee  as  to  prognosis  in  an  individual  case.  The  logical  deduction 
from  this  observation  is  that  we  are  dealing  with  an  infectious  process  in 
which  prostration  is  marked  and  in  which  supporting  treatment  is  urgently 
needed.  The  patient  should  be  kept  in  bed,  while  the  fever  persists,  in  a  room 
of  equable  temperatiire,  not  too  hot,  and  his  diet  should  be  of  fluids  and  as 
nutritious  as  possible.  The  bowels  should  be  opened  by  means  of  repeated 
fractional  doses  of  calomel  followed  by  a  saline.  If  the  patient's  temperature 
must,  in  the  physician's  opinion,  be  lowered  this  may  be  effectually  accom- 
plished by  means  of  the  application  of  an  ice  water  coil  placed  over  the  heart 
or  by  sponging  with  cool  water.  In  most  instances  the  fever  may  be  allowed 
to  run  its  course  undisturbed.  Antipyretic  drugs,  for  their  influence  upon 
this  symptom,  need  not  be  given.  The  use  of  morphine  for  the  pain  is  likely 
to  interfere  with  nutrition,  dam  up  the  excreta  and  leave  the  patient  in  worse 
condition  than  before  its  employment. 

The  treatment  of  the  respiratory  system  consists  first  in  relieving  the  irri- 
tation of  the  nose  and  throat  by  means  of  a  spray  of  ten  drops  (0.66)  of  eucal- 
yptol,  10  grains  (0.66)  of  menthol  to  an  ounce  (30.0)  of  albolene.  One  of  the 
alkaline  antiseptic  sprays  should  be  first  used  in  order  to  dissolve  the  accu- 
mulations of  mucus  as  much  as  possible  and  render  the  mucous  membranes 
clean  in  order  that  the  full  soothing  effect  of  the  oily  spray  may  be  evidenced. 

The  bronchitis  necessitates  the  administration  of  an  expectorant  which 
does  not  disturb  the  heart.  Here  we  may  give  ammonium  carbonate  in 
doses  of  from  5  to  10  grains  (0.33-0.66)  and  repeated  as  frequently  as  the 
condition  may  require,  each  dose  to  be  given  in  two  ounces  (60.0)  of  milk. 
The  exhibition  of  this  drug  will  relieve  unnecessary  coughing,  will  remove 
much  of  the  oppression  of  the  chest,  will  fortify  the  heart  and  has  the  single 
disadvantage  of  being  prone  to  distm"b  the  stomach  after  five  or  six  days. 

If  the  ammonium  carbonate  is  not  well  borne,  strychnine,  either  as  good- 
sized  doses  of  tincture  of  nux  vomica  or  strychnine  sulphate  or  nitrate,  should 
be  administered.  By  the  strychnine  not  only  is  a  stimulant  effect  exerted 
on  the  heart  muscle  and  respiratory  center,  but  also  an  improvement  in 
nutrition  due  to  the  drug's  action  on  the  spinal  cord  is  brought  about.  In  ad- 
ministering alcohol  the  previous  habits  of  the  patient  and  the  urgency  of  the 
symptoms  must  be  considered;  usually  the  patient  is  better  without  it. 

When  the  physical  signs  and  clinical  symptoms  indicate  that  pneumonia 


INFLUENZA.  5 1 

is  present  the  patient  should  be  bled  from  the  less  into  the  greater  circulation 
by  the  nitrites — preferably  glyceryl  nitrate  in  doses  of  ytu  to  5V  of  a  grain 
(0.0006  to  0.0012) — and  increasing  and  frequently  repeated  doses  of  strychnine 
must  be  administered  until  convalescence  takes  place.  In  slowly  resolving 
pneumonias  and  for  an  obstinate  bronchitis  vi^hich  persists  into  convalescence, 
no  drug  yields  better  results  than  creosote  carbonate,  30  or  40  drops  (2.0-2.66) 
given  in  sherry  several  times  a  day. 

In  order  to  eliminate  the  toxins  of  the  disease  the  skin,  bowels  and  kidneys 
must  be  kept  active.     The  pains  may  be  treated  by  the  means  described  below. 

In  the  gastro-intestinal  form  of  epidemic  influenza  the  pain,  nausea  and 
vomiting  require  relief.  At  the  onset  of  the  infection  the  bowels  should  be 
thoroughly  evacuated  by  calomel  given  in  frequently  repeated  small  doses 
(gr.  J-0.016).  Later  intestinal  antisepsis  may  be  accomplished  by  the  admin- 
istration of  the  organic  bismuth  salts,  the  naphtholate,  gr.  v  to  x  (0.33  to  0.66), 
the  iodophenolphthaleinate,  gr.  v  to  x  (0.33  to  0.66)  or  the  subgallate,  gr.  x  to 
XV  (0.66  to  i.o).  High  intestinal  irrigations  are  great  aids  in  the  ehmination 
of  toxins,  not  only  by  the  bowels  but  by  the  kidneys  as  well.  Frequently 
rectal  alimentation  becomes  necessary  when  the  stomach  is  unable  to  retain 
even  liquid  food. 

In  the  nervous  type  the  distressing  pain  particularly  calls  for  treatment 
and,  while  quinine  has  been  much  lauded,  the  author  considers  that  the  results 
obtained  hardly  warrant  its  administration  to  the  extent  that  the  severe 
infection  would  seem  to  justify.  Euquinine  seems  to  be  somewhat  more 
efficient  although  the  statements  made  that  it  causes  tinnitus  are  incorrect. 
Its  dose  is  from  5  to  15  grains  (0.33  to  i.o).  The  giving  of  the  coal  tar  anal- 
gesics has  the  disadvantage  that  the  drugs  of  this  class  that  are  sufficiently 
analgesic  are  also  to  a  greater  or  less  extent  cardiac  depressants;  consequently 
their  unrestricted  employment  is  by  no  means  advisable,  and  may  be  even 
dangerous.  It  is  possible,  however,  to  reheve  the  pain  of  influenza,  to  a 
considerable  extent,  without  dangerously  depressing  the  heart  or  respira- 
tory system.  This  may  be  accomplished  by  alternating  acetphenetidine, 
of  which  the  untoward  effects  are  neutralized  by  combination  with  caffeine, 
with  acetanilide  and  methyl  salicylate,  or  with  antipyrine  salicylate  (sali- 
pyrine),  a  combination  of  antipyrine  and  salicylic  acid.  Of  this  10  grains 
(0.66)  may  be  given  every  2  or  3  hours  until  the  pain  is  relieved.  Depression 
may  follow  the  use  of  this  drug  in  certain  instances  and  it  should  always 
be  employed  with  caffeine  in  consequence.  Kryofine  may  also  be  used  as 
an  analgesic  in  doses  of  from  5  to  8  grains  (0.33  to  0.52)  and  may  prove  more 
effective  and  less  depressant  than  most  of  this  series.  Gelsemium  often  will 
afford  great  relief  from  the  headache  and  backache  which  are  common  in  this 
disease.  It  should  be  pushed  until  slight  ptosis  appears,  when  the  limit 
of  its  physiological  activity  has  been  reached.     This  drug  merits  a  trial,  since 


52  THE    INFECTIOUS    DISEASES. 

the  success,  when  attained,  is  brilHant  aUhough  it  is  difficult  to  furnish  exact 
indications  for  its  administration.  At  times  the  muscular  pains  if  limited 
to  the  back  may  be  mitigated  by  means  of  a  local  application  of  cataplasma 
kaolini.  This  should  be  spread  in  sufficient  thickness  over  the  painful  area, 
covered  with  a  layer  of  muslin  and  kept  hot.  It  is  cleanly,  retains  its  heat 
for  some  time  and  is  easily  renewed.  The  meningeal  symptoms  should  be 
controlled  by  the  use  of  the  ice  helmet  and  the  application  of  cold  to  the  back 
of  the  neck. 

Elimination  of  the  toxins  of  the  disease,  as  has  been  previously  stated,  should 
be  safeguarded.  The  neutralization  of  the  infectious  material  in  the  intestine 
should  be  brought  about  as  has  been  already  shown.  Diarrhoea,  if  pres- 
ent, should  be  considered  beneficial.  Warm  baths  relieve  the  muscular  pain 
and,  when  accompanied  by  friction,  keep  the  skin  in  good  condition  and  add 
to  the  comfort  of  the  patient.  Not  only  should  the  presence  of  albumin  and 
casts  in  the  urine  be  determined  but  the  specific  gravity,  the  urea  excretion  and 
above  all  the  quantity  of  urine  passed  should  be  carefully  noted.  For  urinary 
insufficiency  no  better  treatment  exists  than  continuous  enteroclysis  with 
decinormal  salt  solution  at  a  temperature  of  iio°  F.  (43.5°  C);  this  not  only 
aids  renal  elimination  but  is  a  cardiac  stimulant  of  considerable  efficacy. 

The  treatment  of  influenza  in  children  is  practically  identical  with  that 
of  the  disease  in  adults;  doses  should,  however,  be  regulated  in  accordance 
with  the  age  of  the  patient. 

Complications  should  be  treated  as  when  occurring  independently. 

During  convalescence  the  patient  should  avoid  too  early  exposure  to  out- 
door air  and  any  possible  risk  of  reinfection.  Before  going  out  for  the  first 
time  the  temperature  should  have  been  normal  for  from  five  days  to  a  week. 
Nourishing  diet  and  tonics,  such  as  codliver  oil,  iron,  strychnine  and  the 
vegetable  bitters,  should  be  prescribed. 

DENGUE. 

Synonyms.     Breakbone  Fever;  Dandy  Fever. 

Definition.  An  acute,  infectious  disease  occurring  in  warm  countries, 
characterized  by  severe  pains  in  the  joints  and  muscles,  fever,  and  in  many 
instances,  by  an  erythematous  eruption. 

.Etiology.  This  disease  occurs  chiefly  in  hot  climates  and  during  the 
warmer  and  more  moist  seasons  of  the  year;  it  is  common  in  the  East  and 
West  Indies  but  is  seldom  seen  in  the  United  States  except  along  the  coast 
of  the  Gulf  of  Mexico.  An  epidemic  occurred  in  Galveston,  Texas,  in  1879. 
One  of  the  affection's  distinctive  features  is  its  rapidity  of  diffusion  and  its 
proneness  during  epidemics  to  attack  nearly  all  persons  exposed.  While 
probably  due  to  infection  with  a  micro-organism,  the  specific  cause  of  the  dis- 


DENGUE.  53 

ease  has  not  yet  been  definitely  isolated.  It  is  probably  not  transmitted 
through  contact  with  patients  or  by  means  of  fomites,  the  most  approved 
theory  of  its  means  of  transmission  being  that  certain  gnats  or  mosquitoes 
may  carry  the  infection  from  one  person  to  another. 

Pathology.  Little  is  known  of  the  post  mortem  changes  occurring  in 
this  disease,  deaths  being  very  rare. 

Symptoms.  The  onset  of  the  disease  is  sudden,  without  prodromata,  and 
after  an  incubation  period  of  from  two  to  five  days.  The  invasion  is  marked 
by  a  chill  followed  by  a  rise  in  temperature,  headache,  the  ordinary  symptoms 
of  beginning  febrile  disease,  and  severe  pains  in  the  muscles,  bones  and  joints. 
The  latter  become  hot,  painful,  red,  tender  and  sometimes  swollen.  It  is 
this  joint  involvement  which  gives  the  affection  the  name  "dandy  fever," 
the  gait  being  so  modified  that  it  is  supposed  to  simulate  that  of  a  dandy. 
The  rise  in  temperature  is  rapid,  its  maximum  being  from  103°  F.  to  106°  or 
107°  F.  (39.5°  to  41°  or  41.5°  C).  In  two  or  three  days,  usually  in  two,  the 
fever  falls  rapidly  by  crisis,  with  diaphoresis,  diarrhoea,  diuresis  and  epistaxis. 
With  the  initial  rise  in  temperature  an  erythematous  rash  appears  which 
disappears  synchronously  with  the  fever.  With  the  fall  in  temperature  the 
patient  feels  much  improved  although  weak;  the  pains  are  diminished  but  to 
some  extent  persist.  After  an  afebrile  period  of  from  two  to  four  days  the 
temperature  rises  again  with  a  return  of  the  severe  pains.  The  temperature 
is  usually  less  high  than  in  the  preceding  paroxysm  but  the  pains  may  be 
more  marked.  With  the  fever  a  roseolous  eruption  appears,  first  upon  the 
backs  and  palms  of  the  hands  and  spreads  thence  over  the  entire  body. 
The  macules  are  dark  red,  circular  and  about  the  size  of  a  pea;  they  may  be 
elevated  and  are  likely  to  be  particularly  in  evidence  about  the  joints.  The 
spots  may  coalesce.  As  the  eruption  fades,  which  takes  place  first  upon  the 
hands  and  arms,  then  upon  the  body  and  finally  upon  the  legs,  there  is  a 
fine  desquamation.  The  entire  duration  of  the  disease  is  about  seven  or  eight 
days;  at  the  end  of  this  time  the  rash  has  usually  faded  and  rapid  convales- 
cence ensues.  In  certain  instances,  however,  this  may  be  protracted  and  the 
patient  meanwhile  suffers  from  vague  pains  in  the  joints  and  feet  and  mental 
and  bodily  weakness. 

Lymph  gland  enlargement  may  be  observed  and  the  eruption  may  persist 
for  several  weeks  after  apparent  recovery  has  taken  place.  Delirium  some- 
times accompanies  the  fever  and  muscular  atrophy  has  been  noted  consequent 
upon  an  attack. 

Complications  are  rare  but  relapses  are  not  infrequent. 

In  epidemics  the  diagnosis  of  the  disease  is  not  difficult,  isolated  instances, 
however,  may  be  confounded  with  acute  articular  rheumatism. 

Dengue  is  almost  never  fatal  in  patients  of  moderate  power  of  resistance. 
Death  may  occur  as  a  result  of  other  infections  such  as  pneumonia,  to  which 


54  THE    INFECTIOUS    DISEASES. 

the  patient  is  predisposed  on  account  of  the  weakening  effect  of  the  primary 
disease. 

Treatment.  Isolation,  in  the  light  of  our  present  knowledge  of  the  prob- 
able mode  of  transmission  of  the  disease,  need  not  be  insisted  upon,  but  the 
access  of  mosquitoes  to  the  patient  should  be  prevented.  Disinfection, 
also,  would  seem  to  be  unnecessary. 

Absolute  rest  in  bed  is  an  essential  until  the  termination  of  the  second 
febrile  stage.  At  the  onset  the  bowels  should  be  opened  by  means  of  frac- 
tional doses  of  calomel  followed  by  a  saline,  and  throughout  the  disease  the 
emunctories  should  be  kept  active  by  the  means  suggested  under  the  section 
upon  the  treatment  of  influenza.  The  fever  seldom  needs  special  treatment 
on  account  of  its  short  duration  but  in  instances  of  hyperpyrexia  (105°  to 
107°  F. — ^40.5°  to  41.5°  C.)  cool  sponging  or  one  or  two  tub  baths  may  be 
employed.  These  should  be  given  according  to  the  methods  set  down  for 
use  in  enteric  fever. 

The  pains  may  be  controlled  by  the  employment  of  the  means  indicated 
in  those  of  influenza;  the  salicylates  and  aspirin,  15  to  20  grains  (i.o  to  1.33) 
every  two  or  three  hours  until  the  desired  efi'ect  has  been  produced,  are  also 
useful  in  the  management  of  this  symptom. 

Tincture  of  gelsemium  is  said  to  relieve  the  pain  and  to  lessen  the  cardiac 
excitability;  8  drops  (0.52)  may  be  given  every  three  or  four  hours  until  the 
pain  is  relieved  or  until  the  depression  of  the  pulse  rate  and  the  incidence  of 
ptosis  indicates  that  the  physiological  limit  has  been  reached.  Opium  is 
seldom  necessary  for  the  pain.  Excessive  nervous  symptoms  may  be  controlled 
by  means  of  the  bromides.  In  a  word  the  treatment  of  this  disease  is  entirely 
symptomatic,  no  specific  having  yet  been  discovered. 

The  diet  during  the  fever  should  be  wholly  fluid.  During  convalescence 
tonics  should  be  prescribed  and  strength-giving  foods  given  in  digestible 
form. 

MALARIAL  FEVERS. 

Synonyms.  Chills  and  Fever;  Fever  and  Ague;  Paludism;  Paludal  Fever; 
Swamp  Fever. 

Definition.  Malarial  fever  is  an  infectious  disease  occurring  in  several 
types:  a.  intermittent,  in  which  the  febrile  paroxysm  is  quotidian,  tertian 
or  quartan;  b.  continuous  with  remissions;  c.  pernicious;  d.  chronic  malarial 
cachexia. 

.Etiology.  This  disease  is  less  common  in  the  very  young  and  in  aged 
persons  than  in  young  and  middle-aged  adults;  it  occurs  more  frequently  in 
the  white  than  in  the  negro  race  and  is  most  prevalent  in  low  lands  especially 
in  damp  and  swampy  districts  along  the  sea  coast.     It  is  more  frequently 


MALARIAL    FEVERS.  55 

observed  in  the  tropics  and  the  warmer  portions  of  the  temperate  zones. 
In  the  latter  the  affection  is  rare  in  the  spring,  most  of  the  instances  occurriing 
in  the  late  summer  and  autumn.  In  the  tropics  it  is  most  common  in  the 
months  corresponding  to  the  spring  and  fall. 

The  specific  cause  of  the  malarial  infections  is  a  micro-organism,  the  hcsmo- 
cytozobn,  hcematozodn  or  Plasmodium  malaria.  The  hcEtnaiozodn  malaricB 
is  a  parasitic  body  developing  within  organism  of  all  the  varieties  of  anopheles — 
the  common  mosquito — and  is  transmitted  to  man  through  the  sting  of  this 
insect.  The  parasite  circulates  in  the  blood  of  man,  the  intermediate  host, 
and  occurs  in  three  forms,  each  causing  a  definite  and  different  type  of 
malaria. 

The  haematozoon  of  tertian  fever,  when  seen  soon  after  a  chill,  is  a  small, 
hyaline  body,  rounded  or  irregular  in  shape,  and  is  found  within  the  substance 
of  a  red  blood  cell.  Its  life  cycle  is  of  about  48  hours  duration,  and  consists 
of  the  following  process:  It  first  increases  in  size,  exhibits  amoeboid  move- 
ment and  fine  granules  of  pigment  develop  within  it,  while  the  red  blood  cell 
becomes  larger  and  paler  in  color.  The  pigment  gradually  assembles  itself 
at  the  center  of  the  organism  and  in  about  48  hours  segmentation  takes  place. 
This  process  consists  of  the  division  of  the  original  body  which  now  fills 
nearly  the  whole  of  the  red  cell  into  15  or  20  spores,  resembling  the  original 
hyaline  body.  These  are  set  free  in  the  blood,  each  in  its  turn,  to  prey  upon 
a  red  blood  corpuscle.  At  this  time  the  chill  is  manifested.  Other  fully 
developed  organisms  may  not  undergo  segmentation.  These  are  larger  than 
those  which  sporulate  and  contain  pigment  granules  in  active  movement. 
These  are  a  sexually  different  type  of  the  parasite.  In  the  quotidian  type 
of  the  infection  there  are  two  sets  of  tertian  or  three  sets  of  quartan  organ- 
isms in  the  blood  which  sporulate  upon  different  days  causing  a  chill  every 
24  hours. 

The  quartan  variety  of  the  haematozoon  in  its  earliest  form  closely  resem- 
bles the  tertian  type  but,  as  it  develops,  the  amoeboid  movement  is  more 
sluggish  and  the  grains  of  pigment  are  coarser  and  their  movement  is  less 
active.  It  increases  gradually  in  size,  the  pigment  is  seen  at  its  periphery 
and  on  the  third  day  its  division  into  radially  arranged  segments,  6  to  12  in 
number,  is  noted.  After  a  72  hour  interval  of  development  sporulation  takes 
place.  Here,  as  in  the  tertian  type,  fully  developed  bodies  may  be  observed 
which  do  not  break  up.  These  also  represent  a  sexually  different  form, 
the  gametocytes. 

The  (Bstivo-aiitumnal  organism  is  smaller  than  the  preceding  forms  and 
contains  less  pigment.  Its  full  size  may  be  less  than  half  that  of  a  red  blood 
cell.  Early  in  the  disease  only  small  hyaline  bodies  containing,  it  may  be, 
a  grain  or  two  of  pigment  are  to  be  found  in  the  peripheral  circulation.  The 
more  mature  forms  are  usually  found  in  the  blood  of  the  viscera,  particularly 


56  '  THE    INFECTIOUS    DISEASES. 

that   of   the  spleen,  and  the  bone-marrow,  and  the  corpuscles  containing 
them  may  be  distorted  or  crenated  and  are  of  brassy  color. 

The  characteristic  forms  of  the  aestivo-autumnal  type  of  the  parasite,  which 
are  crescent-shaped,  ovoid  or  spherical,  are  seldom  seen  until  the  infection 
has  been  present  for  a  week  or  more.  These  contain  near  their  centers  groups 
of  coarsely  granular  pigment.  The  crescentic  and  ovoid  bodies  do  not  sporu- 
late  and  represent  the  gametocytes.  The  sexual  forms  of  each  type  of  the 
organism,  entering  the  stomach  of  the  mosquito,  when  an  infected  individual 
is  bitten,  are  fertilized  there  and  after  developing,  the  spores  which  result  may 
be  transmitted  through  the  insect's  bite  to  a  human  host  and  then  undergo 
a  further  cycle  of  development. 

Pathology.  In  acute  infections  there  is  a  diminution  of  the  number 
of  red  cells  and  haemoglobin  in  the  blood  as  a  result  of  the  disintegration  of 
the  former  due  to  the  development  of  the  organism.  The  spleen  is  enlarged 
and  may  rupture,  especially  if  subjected  to  traumatism.  The  parasites 
are  present  in  the  blood. 

In  pernicious  malaria  there  is  marked  anaemia,  the  red  cells  are  distorted 
and  degenerated  and  contain  the  parasites  within  their  substance.  These 
are  also  found  in  the  marrow,  and  this  structure  and  the  spleen  may  be  pig- 
mented and  the  seat  of  a  marked  phagocytosis.  The  spleen  may  be  only 
moderately  enlarged  and  is  usually  dark  in  color  and  soft  in  consistency 
if  the  disease  is  the  result  of  a  recent  infection.  The  liver  is  the  seat  of  acute 
degeneration  (cloudy  swelling).  If  cerebral  symptoms  are  marked  the  brain 
is  congested  and  the  blood  in  its  capillaries  contains  numerous  haematozoa; 
with  severe  intestinal  symptoms  the  parasites  may  be  numerous  in  the  capil- 
laries of  the  intestinal  tract. 

In  malarial  cachexia  the  anaemia  is  pronounced,  the  spleen  is  much  enlarged, 
weighing  at  times  8  or  10  pounds,  its  capsule  is  thickened,  it  is  slate  colored 
on  section  and  contains  pigment.  Its  connective  tissue  framework  is  in  a 
state  of  hyperplasia.  A  like  condition  obtains  in  the  liver.  Melanin  may  be 
deposited  in  the  connective  tissue  beneath  hepatic  capsule.  The  kidneys 
may  be  swollen,  contain  pigment  and,  in  some  instances,  may  be  the  seat  of 
an  acute  or  chronic  nephritis.  The  peritonaeum  and  the  gastro-intestinal 
mucous  membrane  may  be  slate  color  due  to  the  deposition  of  pigment. 

Symptoms.  The  symptoms  of  the  paroxysms  of  quotidian,  tertian  or  quar- 
tan malaria  are  practically  identical  in  their  clinical  manifestation;  they  occur, 
however,  at  diflerent  intervals  depending  upon  the  time  of  sporulation  of  the 
causative  organism.  In  tertian  infection  the  chill  occurs  every  other  day, 
in  quotidian,  daily,  and  in. quartan,  every  72  hours. 

The  incubation  period  of  malaria  is  variable;  it  may  be  as  short  as  one  day 
or  as  long  as  several  months;  the  average  being  from  one  to  two  weeks,  prob- 
ably depending  upon  the  amount  of  infectious  matter  in  the  system. 


MALARIAL    FEVERS. 


57 


The  paroxysm  may  be  preceded  by  prodromal  symptoms  such  as  indefinite 
malaise,  yawning,  headache  or  nausea.  Prodromata  may  be  wholly  absent. 
The  paroxysm  consists  of  three  stages,  the  chill,  the  fever  and  the  sweat. 
The  chill  lasts  from  J  to  2  hours;  it  usually  occurs  late  in  the  morn- 
ing and  almost  never  at  night.  Its  onset  is  usually  gradual  beginning 
with  chilly  feelings  of  increasing  intensity  until  the  body  shivers  with 
cold  and  the  teeth  chatter.  Hot  water  bottles  and  numerous  blankets  will 
not  keep  the  patient  comfortable;  the  face  is  pinched  and  pale;  the  lips  are 
blue,  and  the  patient  is  apparently  very  cold  yet,  at  the  same  time,  the  body 
temperature  is  elevated  even  to  105°  or  106°  F.  (4o.5°-4i.i.°C.).  There  is 
severe  frontal  headache  and  nausea  and  vomiting  may  be  present.  The  pulse 
is  rapid,  tense  and  small.  The  urine  is  pale,  increased  in  amount  and  of  low 
specific  gravity  but  before  this  stage  it  may  have  been  dark  colored  and 


Fig.  5. — Clinical  chart  of  tertian  malarial  fever. 

heavy.  At  the  end  of  the  stage  of  chill  the  febrile  stage  begins.  This  is  char- 
acterized by  flushing  of  the  face,  a  hot  and  dry  skin,  coated  tongue,  great 
thirst,  severe  headache  and  pain  in  the  back  and  limbs;  the  pulse  is  full, 
bounding  and  rapid  and  active  delirium  may  be  present.  The  temperature 
may  be  but  little  higher  than  during  the  cold  stage  and  at  times  the 
maximum  may  be  reached  at  the  termination  of  the  chill.  The  stage 
of  fever  lasts  from  30  minutes  to  four  or  five  hours,  and  is,  at  the  end  of  this 
time,  followed  by  the  stage  of  sweating.  All  the  symptoms  now  subside  and 
there  is  profuse  perspiration  beginning  on  the  face  and  gradually  involving  the 
skin  of  the  whole  body  and  the  patient  falls  asleep  to  awake  later  feeling 


^8  THE    INFECTIOUS    DISEASES. 

perfectly  well.  This  stage  lasts  ^  to  2  or  3  hours.  The  sweating  may  at 
times  be  very  slight. 

The  duration  of  the  whole  paroxysm  is  from  8  to  12  hours,  but  may  be 
shorter.  Splenic  enlargement  may  appear  and  disappear  synchronously 
with  the  paroxysm  but  in  long  continued  infections  this  organ  usually  becomes 
permanently  increased  in  size. 

The  intervals  between  the  paroxysms  differ  with  the  type  of  the  infection. 
Thus  in  simple  tertian  fever  (infection  with  one  set  of  tertian  organisms)  the 
chill  recurs  at  48  hour  intervals.  If  two  sets  of  this  organism,  sporulating  on 
alternate  days,  are  present  the  paroxysm  appears  every  24  hours.  When 
a  single  set  of  quartan  organisms  is  present  the  seizure  takes  place  every 
72  hours,  if  two  groups,  matiu-ing  on  different  days,  are  present,  the  patient 
will  have  two  paroxysms  on  successive  days,  then  a  day  free  from  chill  occurs 
and  the  round  is  then  successively  repeated.  If  three  sets  of  quartan  parasites 
are  present  a  chill  will  occur  daily.  The  chills  may  appear  at  nearly  the 
same  hour  upon  different  days  or  they  may  anticipate — that  is  each  will  occur 
an  hour  or  so  earlier  than  its  predecessor;  also  the  seizures  may  be  retarded, 
appearing  successively  at  a  later  hour. 

Without  treatment  the  paroxysms  may  cease  after  several  have  occurred 
or  they  may  disappear  after  two  or  three  weeks.  In  these  events  they  are, 
however,  very  likely  to  recur.  If  the  disease  continues  the  chronic  form  of 
malaria,  followed  by  cachexia  (q.v.)  supervenes. 

Mstivo-autiimnal  malaria,  after  a  period  of  incubation  similar  to  that 
of  the  foregoing  types,  usually  begins  with  a  chill  which  is  more  frequently 
preceded  by  prodromata  than  is  that  of  the  intermittent  types  of  the  disease. 
There  are  malaise,  general  pains  and  nausea,  often  with  vomiting  of  bile. 
The  chill  may  not  be  well  marked  and  is  followed  by  a  regularly  intermittent 
fever;  the  intermissions  are  longer  than  those  of  the  tertian  type,  or  the  par- 
oxysms may  be  anticipated  or  retarded,  rendering  the  fever  continuous  with 
exacerbations.  This  form  of  remittent  fever  markedly  resembles  enteric 
fever;  the  patient  appears  prostrated,  the  pulse  is  rapid  and  full  and  the 
temperature  rises,  with  daily  remissions,  to  102°  to  104°  F.  (38.9°-4o°  C); 
initial  bronchitis  may  be  present,  jaundice  may  be  observed  and  there  is  acute 
splenic  enlargement.  Nervous  symptoms  may  be  noted.  The  infection 
varies  in  severity;  it  may  ameliorate  after  from  7  to  10  days;  there  may  be 
irregular  remissions  and  exacerbations.  In  the  severe  forms  the  infection 
may  become  of  the  pernicious  type.  Here  the  resemblance  to  enteric  fever 
is  especially  marked.  The  tongue  is  thickly  coated,  the  facies  closely  resembles 
that  of  enteric  fever,  and  the  fact  that  the  two  affections  frequently  occur  in 
the  autumn  renders  the  differential  diagnosis  particularly  difficult.  Blood 
examination  and  the  test  of  quinine  treatment  are  aids  in  the  distinction 
between  the  two  infections. 


MALARIAL    FEVERS.  59 

Pernicious  malarial  fever  is  a  result  of  infection  with  the  hasmatozoon 
of  aestivo-autumnal  malaria  and  occurs  in  three  forms. 

a.  The  comatose  form  may  or  may  not  begin  with  a  chill  but  in  its  severest 
type  this  manifestation  is  usually  well-marked  (the  congestive  chill)  and 
accompanying  it  dehrium,  or  more  often,  coma,  is  rapidly  developed.  The 
skin  is  hot  and  dry  and  the  temperature  ranges  from  104°  to  106°  F.  (40°  to 
41.1°  C).  The  course  lasts  from  12  to  24  hours  and  may  be  followed  by  a 
second  attack.  The  coma  is  a  result  of  the  accumulation  of  the  parasites 
in  the  vessels  of  the  brain  and  may  prove  fatal. 

b.  The  algid  or  asthenic  form  is  characterized  at  its  onset  by  marked 
prostration  and  vomiting;  collapse  may  follow  and,  though  the  patient  may 
complain  of  chilly  sensations,  no  real  chill  may  be  present.  The  surface 
is  cold  and  the  temperature  normal  or  subnormal.  The  pulse  is  small,  rapid 
and  feeble  and  the  respiration  shallow.  Marked  choleraic  diarrhoea  and 
urine  diminished,  sometimes  to  suppression,  may  be  noted. 

These  symptoms  may  continue,  slight  rises  of  temperature  occurring  from 
time  to  time,  for  a  few  days,  at  the  end  of  which  time  death  may  occur  from 
prostration  and  the  severity  of  the  infection. 

c.  The  hcemorrhagic  form.  This  type  includes  black-water  fever  and 
malarial  haemoglobinuria.  It  is  the  result  of  the  malarial  toxin  although 
it  has  been  attributed  to  the  use  of  large  doses  of  quinine;  the  administration 
of  this  drug  may,  however,  aggravate  the  haemoglobinuria.  Black-water  fever 
occurs  in  the  Southern  states,  in  Central  America,  in  Italy  and  in  Africa. 

The  condition  is  met  most  often  in  patients  who  have  had  frequent 
attacks  of  malaria  and  whose  condition  approaches  that  of  the  cachectic 
form  of  the  disease.  The  haemoglobinuria  is  usually  not  accompanied  by 
active  malarial  symptoms  although,  preceding  its  appearance,  a  febrile  move- 
ment may  have  been  present  for  a  few  days.  The  cause  of  the  haemoglo- 
binuria is  certainly  malaria  but  whether  this  manifestation  is  the  result  of 
infection  by  a  distinct  type  of  parasite  is  unknown.  The  exciting  cause  of  the 
paroxysm  has  also  never  been  ascertained. 

Malarial  cachexia  may  result  from  long-continued  exposure  to  and  repeated 
attacks  of  any  of  the  types  of  this  disease.  Its  most  prominent  symptoms 
are  anaemia  and  splenic  enlargement  (ague-cake).  The  anaemia  is  character- 
ized by  a  sallow  skin,  with  sometimes  an  added  subicteroid  tinge,  coated 
tongue,  disordered  digestion  and  constipation,  palpitation  and  dyspnoea, 
oedema  and  coldness  of  the  extremities.  The  temperature  may  be  subnormal 
with  irregular  ascents  to  102°  to  103°  F.  (38.9°  to  39.5°  C).  Haemorrhages 
into  the  retina,  from  the  stomach  and  other  structures  may  be  observed. 
The  examination  of  the  blood  reveals  the  presence  of  a  typical  secondary 
anaemia  and,  it  may  be,  the  presence  of  malarial  organisms,  usually  crescentic 
in  form. 


6o  THE    INFECTIOUS    DISEASES. 

The  edge  of  the  spleen  may  extend  as  low  as  the  crest  of  the  ilium  and  the 
consistence  of  the  organ  is  hard  and  firm. 

Complications  referable  to  the  nervous  system,  such  as  paraplegia,  resulting 
from  a  peripheral  neuritis  or  deranged  circulation  in  the  cord,  hemiplegia, 
acute  ataxia  and  symptoms  suggestive  of  disseminated  sclerosis,  may  occur. 
Areas  of  cutaneous  gangrene  and  testicular  inflammation  have  been  noted. 

The  diagnosis  of  malarial  fever  is  in  most  cases  easily  verified  by  means  of 
examination  of  the  blood,  although  special  training  is  necessary  in  order  to 
become  expert  in  the  detection  of  the  more  unusual  forms  of  the  parasite. 
Further  aids  in  differential  diagnosis  are  absence  of  Widal  reaction  and  of 
leucocytosis  and  the  test  of  treatment  by  quinine. 

The  prognosis  in  simple  intermittent  fever  is  favorable.  Under  proper 
treatment  it  is  easily  curable  and  in  certain  instances  spontaneous  recovery 
takes  place.  Continued  exposure  or  insufficient  treatment  may  result  in  chronic 
malaria.  The  aestivo-autumnal  type  can  usually  be  controlled  by  proper 
treatment  but  may  merge  into  either  the  pernicious  or  the  chronic  type. 
Pernicious  malaria  may  result  in  death  but  recovery  from  malarial  cachexia 
is  the  rule. 

Treatment.  The  prevention  of  this  disease  consists  in  the  employment 
of  means  to  exterminate  mosquitoes,  of  screens  to  prevent  ingress  of  infective 
insects  to  dwellings,  and  in  treatment  of  patients  suffering  from  the  disease 
as  well  as  protecting  them  from  possible  mosquito  bites,  lest  the  infection  be 
thus  transmitted.  In  malarial  regions  all  exposure  to  infection,  especially 
after  nightfall,  is  to  be  avoided.  Prophylactic  doses  of  quinine — two  to 
three  grains  (0.13  to  0.20)  three  times  a  day — should  be  taken  by  individuals 
coming  to  malarial  districts. 

Dvu-ing  the  chill,  endeavors  should  be  made  by  means  of  blankets  and 
hot-water  bottles  and  the  administration  of  hot  drinks  to  keep  the  patient 
warm.  The  headache  may  be  relieved  by  hot  or  cold  applications.  Spong- 
ing with  cold  water  may  be  practised  during  the  febrile  stage  and  the  thirst 
may  be  mitigated  by  frequent  drinks  of  cold  water  or  lemonade.  During  the 
stage  of  sweating  the  patient  may  be  made  more  comfortable  by  wiping  his 
skin  with  hot  flannel. 

The  treatment  of  intermittent  fever  consists  primarily  in  the  administration 
of  quinine.  This  drug  being  absorbed  into  the  blood  exerts  there  a  directly 
poisonous  influence  upon  the  parasites  present  in  the  same  medium.  The 
latter  are  most  susceptible  to  the  effect  of  the  quinine  when  free  in  the  blood 
stream,  that  is,  at  the  termination  of  the  process  of  sporulation,  consequently 
the  drug  should  be  so  administered  that  it  shall  have  been  absorbed  in  time 
to  be  present  while  segmentation  is  taking  place.  In  order  that  quinine  shall 
be  quickly  and  in  sufficient  quantity  absorbed,  measures  should  always  be 
taken  to  render  the  gastro-intestinal  tract — if  the  drug  is  to  be  given  by  mouth 


MALARIAL    FEVERS.  6 1 

— as  active  as  possible  in  performing  this  function,  consequently  it  is  wise 
to  clear  the  intestine,  before  the  administration  of  the  quinine,  by  means  of 
fractional  doses  of  calomel  to  be  followed  by  a  saline.  Then,  in  order  that 
the  blood  shall  be  impregnated  with  the  drug  for  an  hour  or  thereabouts 
before  sporulation  takes  place,  it  should,  when  given  by  mouth,  be  admin- 
istered foiu"  to  six  hours  before  the  expected  paroxysm.  The  quantity  nec- 
essary varies  with  the  severity  of  the  infection  and  the  absorptive  power  of  the 
gastro-intestinal  tract.  In  the  less  severe  types  of  the  disease  15  to  20  grains 
(i.o  to  1.33)  are  often  sufficient  while  in  other  instances  three  or  four  times 
this  amount  may  be  necessary.  For  several  days  following,  the  patient  should 
receive  10  grains  (0.66)  or  more  of  quinine  three  times  a  day,  when  the  dosage 
may  be  reduced  to  five  grains  (0.33)  three  times  a  day.  On  the  seventh  day 
following  the  last  paroxysm  an  amount  commensurate  to  that  administered 
at  the  beginning  of  the  treatment  should  be  given  and  this  procedure  should 
be  continued  every  seventh  day  for  about  two  months.  During  the  first 
two  or  three  days  of  the  treatment  the  action  of  the  quinine  will  be  enhanced 
by  confining  the  patient  to  bed.     After  this  time  he  may  be  allowed  up. 

The  drug  may  be  given  in  solution,  in  pill  form  or  in  capsules.  The  solution 
has  the  disadvantage  of  an  extremely  bitter  taste  and  the  advantage  of  being 
most  readily  absorbed.  Freshly-made  pills  or  soft  gelatin  capsules  con- 
taining the  powdered  drug  are  also  to  be  recommended,  particularly  if  their 
administration  is  followed  by  five  to  eight  drops  (0.33  to  0.5)  of  dilute  hydro- 
chloric acid  to  facilitate  dissolution.  Compressed  tablets  and  stale  pills 
of  quinine  are  very  likely  to  pass  through  the  body  undissolved.  To  patients 
who  cannot  take  the  drug  by  mouth  it  may  be  given  hj^odermatically  in  the 
form  of  the  dehydrochloride  or  of  quinine  and  urea  hydrochloride.  Either 
of  these  may  be  taken  in  doses  of  10  to  20  grains  (0.66  to  1.33)  every  two  or 
three  hours. 

The  following  formulae  are  useful:  I^.  Quininae  sulphatis,  gr.  xv  (i.o); 
acidi  tartarici,  gr.  vii  ss  (0.5);  aquae  destillatai,  itl  cl  (lo.o).  I^.  Quininae 
hydrochloridi,  gr.  Ixxv  (5.0);  aquae  destillatae,  5ii  ss  (lo.o).  I^.  Quininae 
hdyrobromidi,  gr.  xxx  (2.0);  aquae  destillatae,  ttl  xc  (6.0). 

Quinine  hydrobromide  may  also  be  given  subcutaneously.  The  drug 
may  likewise  be  administered  in  enemata  or  suppositories,  the  rectal  dosage 
being  at  least  twice  that  appropriate  by  mouth. 

Substitutes  for  quinine  spring  up  from  time  to  time  and  of  these  quinidine 
sulphate  and  cinchonine  sulphate,  especially  the  latter,  may  be  mentioned. 
The  doses  of  these  are  about  J  greater  than  that  of  quinine  sulphate.  If  in 
long-continued  infections  quinine  fails  to  exert  its  usual  influence  arsenic  may 
be  substituted.  It  may  be  given  in  the  form  of  the  liquor  potassii  arsenitis 
beginning  with  doses  of  five  drops  (0.33)  three  times  a  day  or  as  arsenic 
trioxide,  beginning  dose  ^V  0^  ^  g^^i^^  (0.003)  three  times  a  day.     These 


62  THE    INFECTIOUS    DISEASES. 

doses  should  be  gradually  increased  until  the  physiological  effect  is  evidenced 
by  oedema  under,  the  eyes  or  by  gastro-intestinal  disturbance. 

Methylthionine  hydrochloride  sometimes  succeeds  when  quinine  is  not  well 
borne  or  is  contraindicated,  as  in  pregnancy  or  haemoglobinuria.  Its  action  is 
supposed  to  be  exerted  upon  the  parasite  in  the  blood,  just  as  is  that  of  the  latter 
drug.  It  should  be  given  in  capsules  containing  two  to  three  grains  (0.13  to 
0.20)  each,  of  which  three  per  day  may  be  taken.  The  patient  should  always 
be  warned  that  the  urine  becomes  blue  while  this  drug  is  administered. 

jEstivo-aidumnal  fever  should  be  treated  along  lines  identical  with  those 
described  above.  The  patient  is,  however,  much  more  ill  and  needs  careful 
nursing.  In  the  forms  resembling  enteric  fever  he  should  be  kept  in  bed  and 
receive  fluid  diet  and  stimulants,  especially  strychnine,  as  indicated.  If 
vomiting  is  a  feature  of  the  infection  it  is  likely  to  interfere  with  the  admin- 
istration of  quinine  by  mouth,  consequently  hypodermatic  injections,  as 
described  above,  may  become  necessary.  Enemata  of  quinine  dissolved 
in  starch  water  are  also  useful.  The  vomiting  should  be  treated  sympto- 
matically,  the  bowels  kept  active  and  the  hepatic  torpor  combated  by  means 
of  calomel.     Rectal  feeding  may  be  necessary. 

Pernicious  malarial  fever  demands  the  most  active  and  energetic  treatment. 
The  patient  should  be  kept  in  bed  and  thoroughtly  cinchonized  as  quickly 
as  possible  by  means  of  hypodermatic  injections  of  large  doses.  An  even 
more  rapid  method  is  that  by  intravenous  injection  of  the  drug. 

The  following  solution  may  be  employed:  I^.  Quininae  hydrochloridi, 
gr.  XV  (i.o);  sodii  chloridi,  gr.  i  (0.65);  aquae  destillatae,  5ii  ss  (lo.o). 

The  cerebral  symptoms  may  be  relieved  by  the  bromides  or  by  opium,  if 
necessary,  and  stimulation  by  means  of  strychnine  or  alcohol  may  be  indi- 
cated. The  bowels  should  be  kept  open;  the  chills  may  be  relieved  by  ex- 
ternal warmth  and  the  excessive  fever  by  cool  sponging. 

In  giving  hypodermatic  injections  of  quinine  a  long  needle  inserted  deeply 
into  the  muscular  tissues  of  the  back  or  buttocks,  should  be  used.  Abscesses 
are  very  prone  to  follow  and  in  order  that  they  may  be  prevented,  in  so  far 
as  may  be  possible,  the  strictest  aseptic  technique  should  be  employed. 

Malarial  Cachexia.  Here  quinine  is  also  indicated  although  not  neces- 
sarily in  large  doses,  Warburg's  tincture  containing  10  grains  (0.66)  of  quinine 
to  the  ounce,  often  acts  well  in  doses  of  ^  an  ounce  (15.0)  three  times  a  day. 
Cinchonidine  sulphate  in  doses  of  10  to  15  grains  (0.66  to  i.o)  three  times 
a  day  is  also  useful.  It  is  in  this  form  of  malarial  infection  that  arsenic  is 
particvdarly  indicated,  it  may  be  given  alone  in  the  form  of  liquor  potassii 
arsenitis  or  in  combination  with  iron  and  quinine.  The  following  formulae 
are  suggested:  Quinine  in  pill  form  with  I^.  Ferri  et  potassii  tartratis, 
§ss  (15.0) ;  arseni  trioxidi,  gr.  i  (0.065) !  aquae  destillatae  q.  s.  ad  5iv  (120.0). 
Misce  et  signa,  one  teaspoonful  after  each  meal;  or  I^.   Arseni  trioxidi,  gr.  -gV 


NASHA    FEVER.  63 

(0.003);  massae  ferri  carbonatis,  gr.  v  (0.33).  Misce.  Signa.  Take  one  such 
pill  after  each  meal. 

Arsenic  may  also  be  given  hypodermatically  as  follows:  I^.  Sodii  arsen- 
atis,  gr.  tV  (0.006);  aquae  destillatae  q.  s.;  or,  I^  sodii  arsenatis,  gr,  xV  (0.006); 
sodii  phosphatis,  gr.  ^V  (0.003);  ^odii  sulphatis,  gr.  tV  (0.006);  aquae  destil- 
latae q.  s.;  or,  ^,  ferri  et  ammonii  citratis,  gr.  i  ss  (o.i);  sodii  arsenatis,  gr. 
To  (0.006);  strychninae  sulphatis,  gr.  ^V  (0.002);  aquas  destillatae  q.  s. 

Of  these  one  injection  may  be  given  daily.  Sodium  cacodylate,  §  to  2J 
grains  (0.03  to  0.15)  daily,  may  prove  useful.  In  treating  this  form  of  malaria, 
eitiier  with  or  without  iron,  the  bowels  should  be  kept  regular;  a  course  of 
fractional  doses  of  calomel  may  be  indicated  from  time  to  time  in  order  to 
keep  the  liver  active  and  at  intervals  mild  laxative  pills  may  be  employed. 

The  treatment,  otherwise  than  tuat  discussed  above,  consists  in  the  employ- 
ment of  all  measures,  dietetic,  hygienic  and  hydrotherapeutic,  to  improve 
the  patient's  general  condition,  and,  removal  to  a  different  climate,  a  moun- 
tainous district  if  possible. 

The  Treatment  of  Malarial  Hcsmaturia.  Here,  unless  active  parasites 
are  present  in  the  blood,  it  is  wise  to  omit  quinine  but  should  they  be  found 
this  drug  is  strongly  indicated.  In  the  milder  forms  five  grains  (0.33)  three 
times  a  day  will  cause  this  symptom  to  cease.  Even  when  no  plasmodia  are 
present  certain  writers  advocate  small  doses  of  quinine  beginning  with  one 
grain  (0.065)  ^^'^  watching  the  effect  on  the  haemoglobinuria.  Methylthionine 
hydrochloride,  gr.  ii  to  iii  (0.13  to  0.2)  three  times  a  day,  may  be  given  as 
also  may  sodium  hyposulphite  in  doses  of  20  grains  to  i  drachm  (1.33  to  4.0) 
three  or  four  times  a  day.  Otherwise  the  treatment  of  haemoglobinuria  is 
symptomatic.  The  organs  of  elimination,  the  skin,  kidneys  and  bowels, 
should  be  kept  active  by  means  of  diaphoretics  such  as  pilocarpine  ^  to  ^  of  a 
grain  (0.008  to  o.oii)  given  h^-podermatically  and  with  caution,  and  by  hot 
packs,  by  high  rectal  irrigations  of  hot  saline,  hypodermoclysis  or  intravenous 
infusion.  Stimulant  diuretics  are  to  be  avoided;  cardiac  stimulation  by 
means  of  strychnine  and  the  diffusible  stimulants  is  often  necessary. 

NASHA  FEVER. 

Synonyms.     Nasa  Fever;  Nakra  Fever. 

Definition.  An  acute  infectious  febrile  disease  characterized  by  nasal 
congestion  8,nd  localized  swelling  of  the  septum  nasi. 

Etiology.  This  affection  occurs  in  certain  districts  of  India.  Adults 
are  most  commonly  affected,  the  disease  being  rare  in  children  and  old  persons. 
It  is  observed  chiefly  in  summer  and  is  predisposed  to  by  lack  of  proper 
nourishment,  unhealthy  mode  of  life  and  unsanitary  conditions.  Its  specific 
cause  is  not  known  although  it  has  been  considered  a  form  of  malarial  infec- 


64  THE    INFECTIOUS    DISEASES. 

tion.  The  facts  that  quinine  does  not  influence  its  course  and  that  the  haem- 
atozoon  of  malaria  is  not  constantly  found  are  not  in  accordance  with  this 
theory  of  its  causation. 

Symptoms.  The  characteristic  manifestations  of  this  disease  are  hyper- 
aemia  of  the  nasal  mucous  membrane  and  swelling  of  the  septum  in  particular. 
It  is  ushered  in  by  malaise,  prostration,  and  general  pains  in  the  head,  body 
and  limbs.  The  fever  is  seldom  high  and  there  may  be  a  general  eruption  of 
small  rose-red  spots.  The  febrile  movement  persists  for  from  three  to  five 
days  when  the  temperature  gradually  falls  and  the  other  symptoms  subside. 
A  fatal  issue,  preceded  by  sudden  amelioration  of  the  nasal  manifestations 
and  by  coma,  has  been  observed  in  rare  instances.  Immunity  is  not  conferred 
by  an  attack. 

Treatment  consists  in  employment  of  the  means  indicated  to  control  like 
symptoms  occurring  in  other  infectious  fevers. 

Puncture  of  the  septal  tumor  is  said  to  be  followed  by  an  amelioration  of 
all  the  symptoms. 

CHOLERA. 

Synonyms.  Cholera  Asiatica;  Cholera  Algida;  Epidemic  Cholera;  Cholera 
Jklaligna. 

Definition.  An  acute  infectious  disease  caused  by  a  specific  micro-organ- 
ism and  characterized  by  emesis,  violent  purging,  abdominal  cramps  and 
collapse. 

.Etiology.  This  disease  for  many  years  has  been  endemic  in  India  and 
from  time  to  time  becomes  epidemic.  Epidemics  have  also  occurred  in 
other  parts  of  Asia,  in  Egypt  and  in  Europe,  whence  it  was  first  brought  to 
America  in  1832.  Since  that  time  the  disease  has  visited  this  country 
at  intervals,  the  last  time  being  in  1892  at  the  time  of  a  general  Asiatic  and 
European  epidemic,  when  a  few  instances  were  reported  in  New  York  City. 

The  disease  is  met  in  all  ages  and  both  sexes,  but  children  and  old  persons 
seem  most  prone  to  acquire  the  infection.  Cholera  occurs  more  frequently 
in  low  lying  districts  near  the  sea  coast  than  in  higher  inland  regions,  it  is 
more  common  in  warm  countries  and  prevails  during  the  summer  months 
in  the  temperate  zones.  The  contagium  is  usually  killed  by  the  incidence 
of  frost.  The  infection  is  predisposed  to  by  over-population,  unsanitary 
surroundings,  bad  personal  hygiene,  intemperance  and  any  influence  which 
tends  to  reduce  the  resisting  power  of  the  human  body. 

The  specific  cause  of  Asiatic  cholera  is  the  comma  bacillus  of  Koch  which 
was  discovered  in  1884.  It  is  found  in  the  intestines  of  all  persons  sufi'ering 
from  the  disease,  is  usually  accompanied  by  the  colon  bacillus  and  often  by 
the  streptococcus.     It  is  given  off  from  the  body  in  the  dejecta.     Rarely  is 


CHOLERA.  65 

it  found  in  the  vomitus.    The  disease  is  the  result  of  the  growth  and  propaga- 
tion of  the  bacillus  in  the  body. 

Mode  of  Infection.  The  bacillus  of  cholera  is  taken  into  the  gastro- 
intestinal tract  in  drinking  water  or  upon  food.  The  disease  is  not  contracted 
by  association  with  patients  although  by  handling  the  patient's  discharges 
the  hands  may  become  contaminated  and  in  this  way  the  contagium  may  be 
transferred  to  the  mouth.  Vessels  washed  in  contaminated  water,  vegetables 
washed  or  watered  with  water  containing  the  spirillum,  or  food  upon  which 
flies,  which  have  previously  come  in  contact  with  infectious  matter,  have 
aUghted,  may  transmit  the  disease.  The  spirilla  are  quickly  killed  by  drying, 
consequently  it  is  hardly  probable  that  they  maybe  taken  into  the  system  upon 
the  inspired  air;  they  are  capable,  however,  of  living  upon  bread,  meat  and 
other  foodstuffs  for  from  six  to  eight  days.  The  severity  of  the  infection 
depends  upon  the  amount  of  the  contagious  matter  taken  into  the  system 
and  upon  the  resistance  of  the  individual.  It  is  known  that  the  gastric  juice  is 
decidedly  inimical  to  the  spirillum  and  individual  immunity  has  been  observed, 
virulent  cultures  having  been  isolated  from  the  stools  of  healthy  persons. 

In  direct  opposition  to  Koch's  theory  of  the  propagation  of  cholera  is  that 
of  Pettenkoffer  who  holds  that  the  micro-organism  of  the  disease  develops 
in  the  soil-water  of  the  East  during  the  warm  months  and  rises  thence  as  a 
miasm  into  the  air.  He  asserts  that  conditions  favoring  its  development 
are  a  low-ground  water,  associated  with  porosity,  moisture  and  organic  con- 
tamination, particularly  sewage. 

It  is  not  certain  that  one  attack  of  the  disease  confers  immunity. 

Pathology.  On  gross  inspection  the  body  is  usually  much  emaciated, 
the  skin  over  the  non-dependent  parts  is  grayish  in  color  while  that  over  the 
dependent  portions  of  the  body  is  livid  or  mottled. 

Post  mortem  rise  in  temperature  may  occur  and,  while  rigor  mortis  is  an 
early  manifestation,  contractions  of  the  muscles  of  the  jaws,  the  eyes,  or  of 
the  limbs  may  be  observed.  The  subcutaneous  tissue  when  cut  is  dry,  owing 
to  the  fact  that  the  body  liquids  have  been  drained  away,  and  the  blood  is 
thick  and  dark.  The  peritonaeum  is  viscid,  the  intestines  are  congested  but 
not  distended.  The  stomach  may  contain  a  turbid  liquid  resembling  rice- 
water;  its  mucous  membrane  is  congested  and  its  vessels  are  distended,  the 
epithelium  may  be  eroded  or  intact.  The  lining  of  the  small  intestine  is  usually 
congested  and  the  cavity  of  the  bowel  contains  turbid  serum  (rice-water 
material) ;  in  the  later  stages  the  hyperaemia  is  more  apparent  and  the  solitary 
and  agminated  follicles  may  be  swollen;  rarely  they  may  be  ulcerated.  Ecchy- 
moses  and  denudation  of  the  mucous  membrane  may  be  observed,  the  latter 
probably  having  taken  place  after  death.  Patches  of  false  membrane  may  be 
found  in  the  intestine  in  infections  of  prolonged  course.  The  comma  bacillus 
is  found  in  the  contents  of  the  bowel  and  in  its  mucous  membrane. 
5 


66  THE    INFECTIOUS    DISEASES. 

A  condition  of  acute  parenchymatous  degeneration  (cloudy  swelling) 
obtains  in  the  liver  and  kidneys,  the  former  may  also  show  areas  of  fatty 
degeneration  and  the  latter  coagulation  necrosis  with  desquamation  of  the 
epithelial  lining  of  the  uriniferous  tubules.  The  spleen  is  not  enlarged  and 
may  be  decreased  in  size. 

The  heart  is  dry  and  flaccid.  The  left  auricle  and  ventricle  are  empty 
while  the  right  are  filled  with  dark  liquid  blood.  The  lungs  may  be  shrunken 
and  bloodless,  except  at  the  bases  posteriorly,  where  they  are  likely  to  be  the 
seat  of  passive  congestion. 

Symptoms.  The  incubation  period  is  from  two  to  five  days  after  which 
the  invasion  of  the  disease  occurs.  The  symptoms  may  be  grouped  in  three 
stages  which  are  more  or  less  distinct. 

a.  The  stage  of  preliminary  diarrhoea.  This  stage  may  be  sudden  in 
its  onset  or  preceded  by  abdominal  pain,  malaise,  headache  and  emesis. 
The  diarrhoea  is  painless,  the  stools  are  frequent,  fluid,  yellowish  or  of  "rice- 
water  "  type  and  are  alkaline.  They  contain  the  comma  bacillus  and  other 
micro-organisms;  there  is  usually  no  rise  in  temperature.  This  stage  lasts 
from  a  few  hours  to  a  week  or  more  or  may  be  absent. 

h.  The  stage  of  collapse  is  characterized  by  a  profuse  "  rice-water  "  diarrhoea, 
the  movements  being  very  frequent,  and  apparently  forcibly  expelled.  Parox- 
ysmal pain  and  tenesmus  may  be  present  but  the  patient  is  more  often  dis- 
tressed with  painful  muscular  cramps  in  the  limbs  and  abdominal  wall.  Thirst 
is  marked  and  emesis  is  profuse,  fluid  resembling  the  stools  being  vomited 
incessantly  and  in  great  quantity.  The  patient  rapidly  becomes  exhausted, 
and  often  sinks  into  a  condition  of  collapse  with  sunken  eyes,  shrunken  feat- 
ures, pallid  face,  cold  and  clammy  extremities.  The  surface  temperature 
may  sink  4°  or  5°  F.  (  2°  to  2.5°  C.)  below  normal  while  the  thermometer 
indicates  a  rectal  temperature  of  103°  to  104°  F.  (39.5°  to  40°  C).  The 
pulse  becomes  rapid,  feeble  and  perhaps  imperceptible  at  the  wrist,  the  heart 
sounds  are  markedly  weakened.  Respiration  continues  until  death  super- 
venes in  a  condition  of  coma.  At  times  the  patient  may  remain  conscious 
until  the  very  end.  The  continued  depletion  of  the  patient  during  this  stage 
results  in  great  diminution  of  the  secretions,  particularly  the  urine  and  saliva; 
the  sweat  glands  and,  in  nursing  women,  the  secretion  of  milk  remain  unaf- 
fected. Microscopical  examination  of  the  stools  reveals  the  presence  of 
mucus,  epithelial  cells,  numerous  bacteria,  together  with  the  comma  bacillus, 
and  at  times  blood  ceUs.  Chemically  the  dejecta  contain  albumin,  and  the 
salts  of  the  blood,  particularly  sodium  chloride. 

Cholera  sicca  is  the  term  applied  to  this  disease  when  vomiting  and  diar- 
rhoea are  absent. 

The  usual  duration  of  the  stage  of  collapse  is  from  twelve  to  twenty-four 
hours  although  it  may  last  but  three  or  four  hours. 


CHOLERA.  67 

c.  The  stage  of  reaction,  if  the  patient  survives,  sets  in  at  the  termination 
of  the  stage  of  collapse  and  is  characterized  by  a  reappearance  of  the  secretions, 
of  bodily  warmth  and  of  normal  facial  expression.  The  skin  may  retain  its  mot- 
tled appearance  for  some  days  or  an  erythema  may  appear.  The  symptoms 
gradually  ameliorate,  the  heart  action  becoming  stronger;  the  vomiting  and 
purging  gradually  diminish  and  the  patient  either  may  recover,  there  may 
be  a  recurrence  of  the  diarrhoea  and  collapse  followed  by  death,  or  he 
may  pass  into  a  state  termed  cholera-typhoid  which  is  characterized  by 
cerebral  symptoms,  heart  weakness  and  dry  tongue.  From  this  he  may 
recover  or  death  may  take  place  in  coma  which  is  attributed  to  uraemic 
poisoning. 

Mild  instances  of  cholera,  which  are  termed  cholerine,  are  often  seen  during 
epidemics.  In  such  there  are  diarrhoea,  vomiting  and  abdominal  cramps,  but 
the  collapse  is  not  well  marked.  Malignant  infections  may  also  be  observed 
in  which  death  takes  place  before  the  appearance  of  the  purging  and  emesis, 
or  in  which  the  patient  dies  early  in  the  disease,  comatose  and  in  a  profoundly 
toxaemic  state. 

Such  complications  and  sequels  as  nephritis,  diphtheritic  inflammations 
of  the  mucous  membranes,  and  conditions  due  to  septic  poisoning,  such  as 
parotitis,  erysipelas  and  multiple  abscesses  may  occur.  Pleurisy,  bronchitis 
and  pneumonia  have  been  observed. 

In  the  differentiation  of  Asiatic  cholera  from  other  conditions  likely  to  be 
confounded  with  it  the  chief  points  to  be  kept  in  mind  are  the  history  of 
association  with  other  instances  of  the  disease,  the  presence  of  "rice-water" 
stools,  the  presence  of  painful  cramps  in  the  extremities,  the  occurrence  of 
cyanosis,  collapse  and  suppression  of  the  secretions,  especially  the  urine,  and 
lastly,  the  presence  of  the  comma  bacillus  in  the  dejecta.  A  preponderance 
of  these  symptoms  is  not  likely  to  occur  in  any  disease  except  true  cholera 
and,  of  course,  the  presence  of  the  spirilla  is  pathognomonic. 

The  mortality  varies  in  different  epidemics  from  30  to  80  percent.  The 
disease  is  more  likely  to  prove  fatal  in  the  debilitated  and  intemperate  than 
in  those  of  better  power  of  resistance.  Patients  with  marked  and  early 
collapse  seldom  recover. 

The  prevention  of  this  disease  consists  in  the  prompt  isolation  of  all  patients 
afflicted  with  the  disease  and  the  thorough  disinfection  of  all  dejecta  and 
the  utensils,  bed  and  personal  linen  of  the  sufferer.  The  methods  applicable 
in  enteric  fever  (see  p.  15)  will  be  found  efficacious  in  this  disease.  During 
epidemics  all  water  and  milk  used  for  any  purpose  should  be  boiled  and  it  is 
even  unwise  to  eat  uncooked  fruit  or  vegetables.  The  disease  is  as  slightly 
contagious  as  is  enteric  fever  and  consequently  if  proper  precautions  are 
taken,  those  associating  with  patients  are  not  likelv  to  become  infected. 
The  digestion  should  be  kept  in  perfect  order  and  any  disturbance,  partic- 


68  THE    INFECTIOUS    DISEASES. 

ularly  if  associated  with  diarrhoea,  promptly  treated;  here  opium,  lead  acetate* 
small  doses  of  sulphuric  acid  and  the  salts  of  bismuth,  particularly  those 
which  exert  an  antiseptic  action  upon  the  digestive  tract  such  as  the  sub- 
gallate,  the  naphtholate  and  tetraiodophenolphthaleinate,  are  indicated. 

The  protective  inoculation  against  cholera  by  means  of  Haffkine's  virus 
has  proved  effective  in  the  hands  of  its  originator  and  its  employment  produces 
no  evil  after-effects.  Other  experimenters  are  said  to  have  elaborated  anti- 
toxic sera. 

Since,  however,  we  have  simpler  means,  namely,  through  disinfection, 
sanitation  and  efi&cient  quarantine,  by  which  the  disease  may  be  prevented, 
we  may  remain  content  until  further  research  has  succeeded  in  establishing 
an  anticholera  inoculation  which  shall  be  certainly  protective. 

Treatment.  The  patient  should  be  immediately  isolated  and  put  to  bed. 
During  the  first  stage  of  the  disease  treatment  should  be  directed  at  the  diar- 
rhoea, at  the  destruction  of  the  bacilli  within  the  intestinal  tract  and  at  the 
neutralization  of  their  toxins.  Of  the  drugs  mostcommonly  used  to  check  the 
diarrhoea  opium  and  sulphuric  acid  may  be  mentioned.  It  is  probable  that 
the  latter  is  to  be  preferred,  while  opium  is  to  be  reserved  to  relieve  the  pain; 
for  this  purpose  it  should  be  given  hypodermatically  in  the  form  of  morphine. 
A  full  dose,  gr.  J  to  ^  (0.016  to  0.032),  may  be  given  at  first,  to  be  followed  by 
smaller  doses  as  indicated.  Sulphuric  acid  ha§  a  destructive  effect  upon  the 
comma  bacillus  and  maybe  given  in  the  form  of  the  dilute  acid,  10  to  15  drops 
(0.66  to  i.o),  every  two  or  three  hours.  The  acid  may  be  given  alone  or  with 
the  camphorated  tincture  of  opium.  Hydrochloric  and  nitrohydrochloric 
acids  are  also  useful. 

Excellent  results  have  been  attained  from  the  use  of  phenyl  salicylate  in 
cholera;  it  may  be  given  in  doses  of  gr.  v  to  xv  (0.33  to  i.o)  every  two  or  three 
hours,  alone  or  combined  with  considerable  doses  of  one  of  the  bismuth  salts, 
either  the  naphtholate  or  the  iodophenolphthaleinate,  these  last  being  among 
the  most  effective  intestinal  antiseptics  at  our  disposal.  Calomel  has  also 
given  good  results,  not  only  in  controlling  the  vomiting,  but  since  a  portion 
of  this  drug  is  changed  in  the  digestive  tract  into  mercury  bichloride,  it  has  an 
antiseptic  effect  in  addition.  It  may  be  given  in  dosage  of  from  five  to  seven 
grains  (0.33  to  0.5)  at  the  onset  of  the  disease  and  continued  in  smaller  doses — 
^  to  I  of  a  grain  (0.02  to  0.05) — every  two  or  three  hours  during  the  first  and 
second  stages  of  the  affection. 

If  severe  vomiting  is  present  we  may  attempt  its  control  by  lavage  of  the 
stomach  and  small  doses  of  cocaine — \  to  J  a  grain  (0.016  to  0.032).  When 
this  symptom  is  very  marked  we  should  administer  all  medication  hypo- 
dermatically. In  the  control  of  the  diarrhoea  external  applications  are  often 
useful;  either  mild  mustard  pastes  or  turpentine  stupes  may  be  employed. 
For  the  heart  weakness  the  administration  of  alcohol  and  strychnine  or  of 


CHOLERA.  69 

camphor,  dissolved  in  aether  or  sterile  oil,  i  grain  (0.065)  every  six  or  eight 
hours,  is  indicated. 

During  the  second  stage  the  abdominal  cramps  may  be  relieved  by  hypo- 
dermatic injections  of  morphine  and  the  body  heat  should  be  maintained,  in 
this  as  well  as  in  the  algid  stage,  by  means  of  hot  water  bottles  and,  if  sweating 
is  a  prominent  symptom^  by  the  subcutaneous  administration  of  -j-g-Q  of  a  grain 
(0.0006)  of  atropine  sulphate  which  may  check  this  distressing  manifestation. 

The  continuous  depletion  of  the  system  by  the  serous  diarrhoea  results  in 
marked  thirst  and  serious  diminution  in  the  watery  elements  of  the  tissues. 
The  thirst  may  be  relieved  by  allowing  small  but  frequent  draughts  of  water, 
either  plain  water,  barley  water  or  carbonated  water  being  permissible,  and 
by  intestinal  irrigations  of  hot  normal  saline  solution.  Water  may  be  sup- 
plied to  the  tissues  and  the  organism  stimulated  by  means  of  hypodermato- 
clysis  or  intravenous  injection  of  considerable  quantities  of  normal  saline. 
As  much  as  two  quarts  (2  litres)  may  be  given  under  the  skin  every  four  or 
six  hoiirs.  It  is  often  wise  to  begin  the  hypodermatoclysis  in  the  early 
stages  and  to  continue  it  at  intervals  throughout  the  disease.  During  the 
algid  stage  the  bodily  heat  may  be  kept  up  by  immersing  the  patient  in  a  warm 
bath. 

The  patient  may  receive  for  hypodermatoclysis,  instead  of  normal  saline 
solution,  an  artificial  serum  composed  of  one  drachm  (4.0)  of  sodium  chloride 
and  45  grains  (3.0)  of  sodium  carbonate  to  the  quart  (litre)  of  sterile  water, 
This  should  be  injected  at  a  temperature  of  104°  F.  (40°  C.)  by  means  of  s 
fountain  syringe  or  irrigating  glass  to  the  tube  of  which  a  long  needle  of  mod- 
erate calibre  is  attached.  The  solution  should  be  put  under  the  skin  of  tht 
buttocks,  thighs  or  back;  it  is  well  to  avoid  the  tissues  of  the  neck  lest  oedemu 
of  the  glottis  be  induced.  The  injection  treatment,  also  recommended,  has 
been  followed  by  excellent  results  and  consists  in  irrigating  the  large  intestine, 
through  a  soft  rubber  rectal  tube  passed  as  high  as  possible,  with  an  infusion 
of  chamomile  flowers,  2000  parts,  gum  arable,  30  parts,  tannic  acid,  10  parts 
and  laudanum,  2  parts.  According  to  the  originator  of  this  treatment  the 
tannic  acid  not  only  exerts  its  astringent  action  but  also  inhibits  the  growth  of 
the  comma  bacillus  and  has  a  neutralizing  effect  upon  its  toxins.  The 
solution  is  passed  in  under  gentle  pressure,  the  bag  containing  it  not  being 
elevated  more  than  18  inches  or  two  feet  above  the  patient  who  lies  upon  the 
left  side  with  the  buttocks  raised.  The  fluid  should  be  retained  as  long  as 
possible  and  it  is  said  that  under  favorable  conditions  it  may  pass  the  ileo- 
caecal  valve  and  come  in  contact  with  the  lining  of  the  small  intestine.  The 
injection  may  be  given  four  times  a  day  and  in  severe  infections  may  be 
administered  after  each  movement  of  the  bowels.  If  the  patient  is  in  a  state 
of  actual  or  threatened  collapse  the  solution  should  be  hot — io5°F.  (40.5°  C.) 
— ^but  should  there  be  tendency  to  hyperpyrexia  it  may  be  cool.     The  tern- 


70  THE    INFECTIOUS    DISEASES. 

perature  of  the  fluid  in  its  receptacle  if  it  is  to  be  given  hot  should  be  112° 
to  116°  F,  (44.5°  to  46.5°  C.)  since  by  the  time  it  has  reached  the  body  much 
of  its  heat  will  have  been  lost  in  its  slow  passage  through  the  tube.  The 
tendency  to  urinary  suppression  is  also  lessened  by  the  hot  irrigations  and 
may  be  still  further  combated  by  means  of  hot  applications  over  the  lumbar 
region. 

During  the  stage  of  reaction  the  substitution  for  the  tannic  acid  mixture 
of  saline  solution  (sodium  chloride,  10  to  15  percent.)  is  advisable  and  when 
the  tissues  seem  still  to  be  in  need  of  water,  as  evidenced  by  thirst  and  relaxa- 
tion of  the  skin,  the  hypodermatoclysis  should  be  continued  at  increasing 
intervals.  Stimulants  may  also  be  necessary.  When  convalescence  has 
become  established  the  patient  should  be  still  kept  at  rest  and  fed  with  the 
greatest  caution  lest  the  diarrhoea  recur.  The  food  should  be  given  at  fre- 
quent intervals  but  in  very  small  amounts  and  must  be  of  the  most  non-irri- 
tating character.  Peptonized  milk  is  the  first  nourishment  and  may  be 
followed  by  other  peptonized  foods.  Later  more  liberal  feeding  may  be 
permitted  and  tonics  should  be  judiciously  administered. 

Complications  should  receive  appropriate  treatment. 

Dead  cholera  bacilli  in  anticholera  vaccination  have  been  employed  with 
the  result  of  apparently  certain  immunization  and  the  Japanese  have  an 
antitoxin  which  is  said  to  be  curative,  when  properly  administered,  unless 
the  patient  is  in  extremis. 

DYSENTERY. 

Synonym.     Bloody  Flux. 

The  term  dysentery  is  applied  to  a  group  of  infectious  inflammatory  intestinal 
affections  characterized  by  ulceration  of  the  intestinal  mucous  membrane 
and  frequent  dejections,  associated  with  pain  and  often  containing  mucus 
and  blood.  In  chronic  forms  of  dysentery  constipation  may  alternate  with 
the  diarrhoea. 

The  conditions  to  be  included  under  the  term  dysentery  may  be  classified 
as  follows:  a,  Catarrhal  or  sporadic  dysentery;  b,  tropical  or  epidemic 
dysentery;     c,  amoebic  dysentery;     d,  diphtheritic  dysentery. 

.etiology.  Aside  from  the  specific  causes  of  these  different  types  of  the 
disease  certain  predisposing  aetiological  factors  are  common  to  all  forms. 
Dysentery  is  especially  a  disease  of  warm  climates,  although  its  epidemic 
and  other  varieties  have  been  observed  in  northern  latitudes.  Season  also 
has  a  distinct  influence  upon  the  occurrence  of  dysentery,  the  disease  being 
most  prevalent  during  the  warm  months  of  the  summer  and  autumn.  Damp 
low-lying  regions  near  the  sea  shore  suffer  more  frequently  than  highland 
and  inland  districts.     Unhygienic  conditions  of  life,  unsanitary  surroundings 


DYSENTERY.  7 1 

and  over-crowding  predispose  to  the  incidence  of  the  disease  as  is  evidenced 
by  the  epidemics  which  occur  from  time  to  time  in  army  camps,  jails,  hospitals 
a^nd  the  Hke. 

Dysentery  affects  all  ages,  both  sexes  and  all  races.  Barring  the  proneness 
of  infants  to  dysenteric  disturbances  the  disease  is  most  commonly  seen  in 
young  adults.  It  is  predisposed  to  by  all  disorders  of  the  intestinal  tract 
and  by  errors  in  diet,  particularly  the  eating  of  unripe  or  over-ripe  fruit. 

Catarrhal  Dysentery. 

Synonym.     Sporadic  Dysentery. 

.Etiology.  This  form  of  dysentery  is  met  as  a  complication  of  the  various 
acute  infectious  diseases  as  well  as  of  chronic  wasting  diseases,  such  as  tuber- 
culosis. It  is  predisposed  to  by  the  ingestion  of  irritating  and  improper 
food  and  is  the  type  of  dysentery  met  so  frequently  in  children  during  the 
summer  months.  Here  it  is  usually  a  primary  disease  and  it  may  occur  as 
such  in  adults. 

Its  specific  cause  is  in  all  probability  the  result  of  the  presence  and  growth 
in  the  intestine  of  the  Shiga  bacillus  or  analogous  micro-organisms  of  which 
several  varieties  may  be  present  in  the  same  case. 

Pathology.  The  morbid  changes  depend  upon  the  severity  of  the  infec- 
tion and  may  consist  merely  of  an  increased  production  of  mucus,  exfoliation 
of  the  epithelial  cells  lining  the  large  intestine,  exudation  of  serum  and  dia- 
pedesis  of  white  blood  cells.  In  more  marked  infections  there  is  swelling  of 
the  solitary  follicles  which  is  followed  by  necrosis  and  ulceration;  haemor- 
rhages from  tKe  mucous  membrane  may  occur  and  this  structure  may  be 
the  seat  of  a  purulent  inflammation. 

Symptoms.  The  onset  of  the  disease  may  be  preceded  by  such  prodromata 
as  malaise, abdominal  pain, nausea  and  moderate  diarrhoea, or  it  maybe  sudden 
and  marked  by  a  chill  followed  by  a  slight  or  moderate  rise  in  temperature 
which  seldom  is  higher  than  103°  to  104°  F.  (39.5°  to  40°  C).  The  typical 
symptoms  are  cramp-like  pains  in  the  abdomen  accompanied  by  movements 
from  the  bowels  with  tenesmus.  At  first  these  number  not  more  than  five 
to  six  per  day,  are  copious  and  consist  of  faecal  matter;  soon  they  become 
much  increased  in  number,  even  to  100  or  more  per  day,  are  small,  mucoid 
and  at  times  bloody. 

Microscopic  examination  of  the  stools  reveals  the  presence  of  mucus,  red 
blood  and  pus  cells,  epithelial  cells,  which  may  have  undergone  partial  fatty 
degeneration,  and  the  bacteria  of  putrefaction. 

After  a  week  or  ten  days  the  stools  become  less  frequent,  contain  less  mucus 
and  blood  and  are  greenish,  due  to  the  presence  of  bile. 

Other  symptoms  manifested  in  this  disease  are  a  coated  tongue,  at  first 


72  THE    INFECTIOUS    DISEASES. 

moist,  later  dry,  loss  of  appetite,  rarely  vomiting,  and  marked  thirst.  The 
patient  soon  becomes  emaciated  and  a  condition  of  collapse,  with  small 
weak  pulse  and  moist  clammy  skin,  may  be  observed.  Occasionally  delirium 
followed  by  coma  and  death  may  be  met. 

The  usual  course  is  one  week  to  ten  days  after  which  the  stools  begin  to 
approach  the  normal  in  number  and  character,  but  at  times  the  disease  will 
resist  treatment  for  a  long  period  or  even  become  chronic.  Death  occurs  in 
rare  instances  from  exhaustion. 

The  diagnosis  is  to  be  based  upon  the  character  of  the  stools  and  the  intes- 
tinal symptoms.  In  protracted  instances  rectal  examination  should  always  be 
made  in  order  to  exclude  malignant  tumor. 

Tropical  Dysentery. 

Synonyms.     Epidemic  Dysentery;  Bacillary  Dysentery. 

Definition.  A  specific  inflammation  affecting  the  colon  and  sometimes 
the  small  intestine  and  characterized  by  the  exudation  of  a  false  membrane 
which  may  be  cast  off,  leaving  ulcerating  surfaces  behind. 

Etiology,  This  affection  is  a  common  disease  of  tropical  and  temperate 
climates  and  is  especially  prone  to  appear  where  large  numbers  of  persons  are 
gathered  under  unsanitary  surroundings,  as  in  army  camps,  ships  and  hos- 
pitals. It  often  appears  in  epidemics.  Its  specific  cause  is  the  bacillus 
dysentericE  discovered  by  Shiga  during  an  epidemic  in  Japan.  Other  observers 
have  confirmed  his  observations  in  the  Philippine  Islands  and  in  other  coun- 
tries. This  micro-organism  is  not  found  in  the  normal  intestine  but  may 
persist  in  this  situation  after  an  attack  of  the  disease  which  may  account 
for  the  dissemination  of  the  infection  in  regions  where  it  has  been  prevalent. 
It  has  appeared  in  the  United  States  since  the  return  of  our  soldiers  from 
China  and  from  the  West  Indies.  Its  mode  of  transmission  is  by  means  of 
drinking  water  or  other  contaminated  ingesta. 

Pathology.  The  changes  observed  depend  upon  the  severity  of  the 
infection.  In  mild  forms  the  mucous  lining  of  the  intestine  is  inflamed, 
swollen  and  covered  with  a  croupous  exudate  which  is  easily  detachable  and 
is  composed  of  necrotic  epithelium.  In  the  more  severe  grades  this  exudate 
involves  all  the  coats  of  the  intestine  and  appears  as  a  grayish  or  brownish 
mass  of  granular  surface  which  may  cover  the  entire  lining  of  the  colon 
or  may  affect  localized  areas  only.  Portions  of  this  pseudo-membrane  may 
be  sloughed  away,  ulcers,  varying  in  extent,  being  left  behind.  A  follicular 
form  of  inflammation  may  occur  without  membrane  formation  in  which  the 
intestinal  lining  is  at  first  swollen  and  congested,  the  follicles,  especially  those 
of  the  ccecum,  being  inflamed  and  ulcerated.  These  ulcers  may  extend  to  the 
muscular  coat;  their  edges  are  ragged  and  overhanging.     Cicatrization  may 


DYSENTERY.  73 

take  place,  and  ulcerations  in  all  stages  may  be  observed  at  the  same  time. 
In  other  instances  a  gangrenous  process  may  follow  the  diphtheritic  inflam- 
mation. Here  the  serous  coat  is  affected  and  adhesions  are  common;  the 
wall  of  the  gut  is  easily  torn,  is  necrotic  and  dark  olive  green  in  color  with  here 
and  there  areas  which  are  quite  black.  Its  linmg  is  the  seat  of  diffuse  puru- 
lent infiltration  with  localized  areas  of  necrosis  and  gangrene.  Portions 
of  the  mucosa  may  not  be  involved  in  the  above  described  types  of  inflam- 
mation but  are  the  seat  of  simple  catarrhal  changes. 

Symptoms.  The  onset  is  usually  sudden  and  may  be  characterized  by 
a  chill.  The  temperature  rises  rapidly — 102°  to  103°  F.  (39°  to  39.5°  C.) — 
the  prostration  is  marked  and  cerebral  symptoms,  even  delirium,  may  be 
present.  The  temperature  is  irregular  with  remissions  from  time  to  time, 
the  pulse  is  rapid  and  soon  becomes  feeble;  irregularity  of  force  and  frequency 
may  be  noted. 

There  is  severe  abdominal  pain  and  the  stools  are  frequent,  small,  dark  in 
color,  foetid  and  contain  mucus  and  blood.  Pieces  of  pseudo-membrane  may 
be  cast  off,  varying  from  a  small  shred  to  a  tube  cast  of  the  gut  of  considerable 
size.  Tenesmus  is  likely  to  be  a  distressing  symptom  and  the  abdomen  may 
be  distended  and  tender.  In  persistent  cases  the  stools  are  likely  to  become 
serous  and  more  profuse.  Such  dejecta  are  markedly  albuminous,  and  may 
be  reddish,  due  to  the  presence  of  blood.  The  patient  becomes  rapidly 
weak  and  emaciated  and  suffers  from  thirst;  the  mouth  is  dry  and  the  tongue 
foul  and  coated.  In  severe  infections  there  may  be  delirium  followed  by 
coma.  Milder  subacute  types  of  the  disease  may  occur  in  which  the  symp- 
toms are  not  marked  and  the  stools  as  few  as  five  or  six  per  day. 

The  diagnosis  may  be  made  upon  the  rapid  development  of  intestinal 
and  constitutional  symptoms,  and  the  appearance  of  bits  of  membrane  in  the 
dejecta.  It  is  assured  by  the  isolation  of  Shiga's  bacillus  from  the  stools 
and  by  obtaining  a  positive  agglutination  reaction  with  pure  cultures  of  this 
bacillus  when  mixed  with  the  blood-serum  of  the  patient. 

The  prognosis  in  this  type  of  dysentery  is  distinctly  unfavorable,  recovery 
may,  however,  occur  or  the  disease  may  become  chronic. 

Complications,  such  as  localized  peritonitis,  intestinal  rupture  with  subse- 
quent general  peritonaeal  infection,  may  be  observed.  Hepatic  abscess  is  less 
frequent  than  in  amoebic  dysentery.  Pleurisy,  pericarditis  and  endocar- 
ditis are  infrequent  complications. 

Amoebic  Dysentery. 

Definition.  An  inflammation  of  the  large  intestine  characterized  by 
the  formation  of  ulcers  and  due  to  the  amceha  coli. 

.Etiology.     This  disease  is  most  common  in  tropical  countries  but  has 


74  THE   INFECTIOUS   DISEASES. 

also  been  observed  in  the  southern  United  States  and  more  infrequently  in 
those  farther  north.  It  may  occur  at  any  age  but  is  most  common  during 
the  third  decade  of  life  and  seems  to  affect  males  more  frequently  than  females. 
Its  specific  cause  is  the  amceba  coli  which  is  found  in  the  stools,  the  intestinal 
ulcerations  and  in  the  pus  from  liver  abscesses  which  commonly  complicate  the 
disease.  This  organism  is  from  15  to  20  microns  in  diameter,  spheroidal  in 
form  and,  when  living,  actively  motile.  It  is  composed  of  two  portions,  an 
outer,  the  ectosarc,  and  an  inner,  the  endoscarc.  It  moves  by  propelling  the 
former,  after  which  the  endosarc  follows  by  flowing  into  the  pseudopodia 
thus  extruded.  The  amoeba  is  phagocytic,  taking  into  its  substance  red  blood 
cells  and  other  bodies  occurring  in  the  intestine.  It  is  said  that  the  virulence 
of  the  amceba  is  much  enhanced  by  the  presence  of  the  various  pyogenic 
bacteria. 

Its  mode  of  transmission  is  usually  by  means  of  drinking  water  or  upon 
other  ingesta  contaminated  with  infective  water,  and  consequently  the  disease, 
of  which  it  is  the  cause,  may  be  in  great  measure  prevented  by  proper  attention 
to  water  supply  and  by  thorough  disinfection  of  the  discharges  of  affected 
individuals. 

Pathology.  The  intestinal  changes  are  confined  almost  wholly  to  the 
large  intestine  and  are  but  seldom  found  in  the  ileum.  The  ulceration 
involves  first  the  submucosa  of  the  gut  but  spreads  thence  to  the  mucosa.  The 
muscularis  is  rarely,  and  the  peritonaeal  coat  still  more  seldom,  affected.  The 
first  changes  noted  are  a  number  of  areas  of  congestion  in  the  submucous 
coat;  these  are  followed  by  necrosis  of  this  and  a  sloughing  process,  which 
involves  the  mucous  coat  as  well,  and  leaves  behind  ulcers  of  varying  size 
and  depth.  The  peritonaeal  coat  rarely  shares  in  the  inflammation  and 
perforation  is  a  rare  occurrence.  Pus  is  present  in  svirprisingly  small 
amount  considering  the  extent  and  type  of  the  process  and  extensive 
necrosis  of  the  submucosa  may  be  observed  with  no  or  only  slight  involve- 
ment of  the  mucosa,  the  inflammation  dissecting  its  way  downward  and 
laterally  rather  than  toward  the  lumen  of  the  intestine.  The  ulcers  may 
be  circular  or  ovoid,  they  have  ragged  floors  and  overhanging  edges  and  may 
involve  nearly  the  whole  of  the  colonic  lining  including  that  of  the  appendix. 
In  them  the  amoebae  are  present;  these  may  also  be  found  in  the  lymph 
spaces  and  more  rarely  in  the  neighboring  blood-vessels. 

As  the  ulcers  heal,  their  bases  become  covered  with  fibrous  tissue  which 
may  later  contract  and  cause  strictures  or  even  sacs  in  which  the  amoebae 
may  remain  after  the  patient  seems  to  have  recovered.  Thickenings  and 
adhesions  of  the  colonic  wail  may  be  observed. 

The  hepatic  lesions  are  probably  the  result  of  the  entrance  of  the  parasites 
into  the  portal  capillaries  and  are  of  two  types:  First,  multiple  circum- 
scribed areas  of  necrosis,  and  second,  abscesses,  single  or  multiple.      The 


DYSENTERY.  '  75 

former  lesions  are  thought  to  be  due  to  the  action  of  the  products  of  the 
growth  of  the  parasite,  the  latter,  if  recent,  contain  within  their  cavities,  which 
are  large  if  single,  small  if  multiple,  necrotic  matter  of  semi-fluid  consistency 
and  reddish — or  greenish — ^yellow  color.  On  close  inspection  this  is  seen  to 
be  composed  of  a  spongy  net-work  of  tissue  in  the  interstices  of  which  a  viscid 
fluid  is  confined.  The  walls  of  the  recent  abscesses  are  ragged  and  necrotic 
while  those  of  long  standing  are  lined  by  firm,  dense  fibrous  tissue.  Micro- 
scopic examination  of  the  contents  of  the  abscesses  reveals  the  presence  of 
necrotic  liver  cells  and  amoebae.  True  pus  is  not  present  unless  mixed  infec- 
tion has  taken  place.  Such  pyogenic  bacteria  as  staphylococci,  streptococci, 
colon  bacilli,  etc.,  have  been  found. 

Large  single  abscesses  are  usually  near  the  upper  or  lower  surfaces  of  the 
right  lobe  while  the  small  multiple  abscesses  are  scattered  through  the  organ 
and  may  be  at  no  great  distance  from  its  surface. 

Hepatic  abscesses  may  rupture,  depending  upon  their  site,  into  any  of  the 
surrounding  organs  or  through  the  abdominal  wall.  They  may  perforate 
the  diaphragm  and  burst  into  the  lung,  whence  their  contents  may  be  coughed 
up. 

Associated  lesions  which  may  be  observed  are  nephritis  and  cerebral  conges- 
tion, with  or  without  capillary  haemorrhages. 

Symptoms.  In  cases  of  acute  onset  the  symptoms  are  practically  those 
of  dysentery  due  to  the  bacillus  of  Shiga  (see  p.  73).  The  temperature  is 
seldom  high  but  the  patient  is  greatly  prostrated  and  becomes  rapidly  and 
to  a  marked  degree  emaciated.  Intestinal  haemorrhage  or  perforation  may 
occur.  While  recovery  usually  takes  place  in  two  or  three  months,  in  severe 
grades  of  the  infection  death  may  take  place  within  a  week  or  ten  days  or, 
the  disease  becoming  chronic,  the  patient  continues  to  suffer  from  alternating 
diarrhoea  and  constipation,  exacerbations  occurring  from  time  to  time  during 
which  the  pain  and  temperature  recur  and  diarrhoea  with  the  passage  of 
mucus  and  blood  makes  its  appearance.  Between  the  exacerbations  the  patient 
enjoys  periods  of  improvement  but  a  recurrence  of  the  symptoms  may  be 
brought  about  by  errors  in  diet  or  exposure;  while  often  enough  the  patient's 
nutrition  remains  good,  in  other  instances  emaciation  may  be  marked. 

In  another  chronic  type  of  the  disease  the  ulceration  persists  and  with  it 
the  diarrhoea;  the  emaciation  is  progressive  and  death  from  exhaustion  super- 
venes within  a  few  months. 

The  complication  to  be  particularly  anticipated  is  liver  abscess,  the  presence 
of  which  is  evidenced  by  an  increase  in  the  area  of  liver  dulness,  pain,  leuco- 
cytosis  and  a  temperature  of  septic  type  accompanied  by  chills  and  sweating. 
Other  possible  complications  are  peritonitis,  intestinal  haemorrhage  or  per- 
foration, pylephlebitis,  pleurisy,  pericarditis,  endocarditis  and  arthritis. 
Malaria  and  enteric  fever  have  been  observed  in  co-existence  with  this  disease. 


76  THE    INFECTIOUS    DISEASES. 

The  diagnosis  of  this  affection  is  to  be  based  upon  the  finding  of  the  amoebae' 
in  the  patient's  dejecta.  They  should  be  searched  for  upon  a  warmed  stage 
and  a  positive  diagnosis  should  not  be  made  unless  amoeboid  movement 
is  observed. 

The  prognosis  of  amoebic  dysentery  in  epidemics  and  without  proper  treat- 
ment is  unfavorable;  in  sporadic  cases  the  mortality  is  low.  Recurrences 
are  prone  to  occur  and  in  the  patients  in  whom  the  disease  is  compHcated 
by  hepatic  abscess  the  chances  of  recovery  are  greatly  diminished. 

Diphtheritic  Dysentery. 

This  form  of  dysentery  occurs  secondary  to  the  acute  infectious  diseases, 
pneumonia,  enteric  fever,  etc.,  and  to  certain  chronic  affections  such  as  endo- 
carditis, nephritis  and  pulmonary  tuberculosis. 

Pathology.  While  termed  diphtheritic  this  condition  is  not  a  result  of 
Klebs-Loffler  infection.  It  is  characterized  by  the  appearance  of  a  pseudo- 
membranous exudate  of  yellowish  or  grayish  color  upon  the  mucous  lining 
of  the  intestine  and  by  necrotic  ulcerative  areas.  The  supporting  connective 
tissue  of  the  colonic  glands  is  inflamed  and  infiltrated  with  fibrin  and  pus 
cells.  The  process  may  involve  the  muscular  and  peritonaeal  coats  as  well. 
The  inflammation  may  be  confined  to  the  rectum  or  the  whole  colon  may  be 
involved,  its  entire  surface  being  covered  with  the  exudate  or  merely  scattered 
areas  of  pseudo-membrane  being  present.  In  markedly  severe  instances  the 
necrotic  patches  may  slough  leaving  ulcers  behind  which  cither  cicatrize  or 
remain  active  for  long  periods. 

Symptoms.  The  onset  of  this  disease  is  gradual,  being  characterized 
by  the  appearance  of  slight  or  moderate  diarrhoea,  the  stools  being  fluid,  not 
often  accompanied  by  pain  or  tenesmus  and  seldom  more  than  from  three  to 
five  daily.  In  mild  instances  the  passage  of  mucus  and  blood  is  rarely  observed 
but  in  the  severer  types  of  the  disease  these,  with  shreds  of  membrane,  may 
appear  in  the  dejecta.  The  affection  is  usually  subacute  or  chronic  in  its 
course  and  is  associated  with  emaciation.  Death  may  take  place  from  asthe- 
nia. 

The  Treatment  of  Dysentery. 

Under  this  caption  the  means  applicable  to  the  treatment  of  all  types  of 
the  affection  will  be  first  discussed,  to  be  followed  by  a  description  of  those 
especially  indicated  in  the  different  forms  of  the  disease. 

General  Considerations.  In  all  forms  of  dysentery  the  prophylaxis  consists 
in  boiling  all  possibly  contaminated  drinking  water,  disinfecting  and  des- 
troying the  patient's  dejecta  and  in  taking  all  the  other  precautions  laid  down 
in  the  section  upon  the  prevention   of  enteric  fever  (p.  15).     Much  work 


DYSENTERY.  77 

has  been  recently  undertaken  along  the  lines  of  preventive  inoculation  against 
bacillary  dysentery  and  it  is  quite  probable  that  we  may  in  the  not  far  distant 
future  have  at  our  disposal  an  efiective  immunizing  serum  against  Shiga 
bacillus  infection. 

At  the  onset  of  any  of  the  varieties  of  dysentery  the  patient  should  be  imme- 
diately put  to  bed  and  if  the  catarrhal  type  is  the  one  in  hand  a  purge  of 
castor  oil,  one  ounce  (30.0)  with  20  grains  (1.33)  of  sodium  bicarbonate  should 
be  given. 

The  pains  and  tenesmus  may  be  controlled  by  the  application  to  the  abdomen 
of  turpentine  stupes  or  mild  sinapisms  and  by  the  administration  of  Dover's 
powder  by  mouth.  In  instances  where  these  means  fail  morphine  may  be 
given  hypodermatically. 

The  feeding  of  the  patient  offers  difl&culties,  for  we  have  a  disturbed  diges- 
tive tract  and  one  which  must  be  irritated  as  little  as  possible,  and  at  the  same 
time  we  have  to  combat  a  disease,  one  of  the  most  prominent  characteristics 
of  which  is  loss  of  strength  and  emaciation.  Milk  has  its  disadvantages  since 
the  curds  which  are  formed  in  the  stomach  may  be  impossible  of  digestion  by 
an  alimentary  tract  the  powers  of  which  are  impaired;  the  curds  also  are 
excellent  culture  media  for  the  growth  of  the  micro-organisms  which  are 
present  in  the  intestine.  Curd  formation  may  be  prevented  by  taking  the 
milk  in  small  amounts  and  diluted  with  Hme  water  or  vichy  or  barley  water, 
or  in  the  form  of  kumyss  or  zoolak.  ~  Peptonized  milk  may  also  be  tried,  soups 
and  broths  may  be  permitted.  When  milk  is  not  well  borne  easily  digestible 
semi-solids,  which  may  be  partly  predigested  by  means  of  pancreatin  or 
diastase,  such  as  soft  boiled  eggs,  meat  jellies,  milk  toast,  junket,  etc.,  are 
allowable. 

The  diet  in  the  protracted  forms  of  diphtheritic  or  amoebic  dysentery  may 
be  more  liberal.  While  milk  plays  an  important  part  here,  such  nourishing  and 
easily  digestible  solids  as  raw  oysters,  cereals,  poultry  and  fish  may  be  given 
in  small  quantities  and  tentatively.  As  the  patient  recovers  a  still  more 
liberal  dietary  may  be  gradually  permitted. 

Various  forms  of  drug  treatment  may  be  employed  in  catarrhal  and  bacillary 
dysentery;  the  so-called  saline  treatment  is  indicated  particularly  in  sthenic 
cases  with  high  fever  and  in  many  instances  achieves  excellent  results.  Instead 
of  the  initial  dose  of  castor  oil,  a  purgative  dose  of  magnesium  sulphate  or 
sodium  and  potassium  tartrate  is  given  and  the  intestine  is  thoroughly  evacu- 
ated. Then,  upon  the  theory  that  intestinal  micro-organisms  cannot  exist 
or  at  least  are  inhibited  in  their  growth  by  an  acid  medium,  aromatic  sul- 
phuric acid  is  given  in  20  drop  (1.33)  doses  three  times  a  day.  By  this 
means,  not  only  are  the  intestinal  bacteria  retarded  in  their  development, 
but  the  astringent  action  of  the  acid  is  also  exerted. 

The  ipecac  treatment  may  be  employed  in  all  forms  of  dysentery  and  is 


78  THE    INFECTIOUS    DISEASES. 

to  be  carried  out  as  follows:  The  drug  is  administered  upon  the  empty 
stomach  and  it  may  be  wise  to  apply  counter- irritation  over  the  stomach  in  the 
form  of  a  mild  mustard  paste  or  by  painting  the  skin  with  iodine  before  giving 
the  ipecac.  The  amount  of  this  drug  which  is  administered  is  large  and 
under  ordinary  circumstances  would  produce  emesis,  consequently  the  patient 
should  not  be  told  of  what  the  medication  consists  and  he  should  be  warned 
not  to  vomit  if  he  can  avoid  it.  The  size  of  the  dose  is  in  proportion  to  the 
severity  of  the  disease  and  weakness  is  not  a  contra-indication.  Preceding 
the  administration  of  the  ipecac  a  dose  of  lo  to  15  drops  (0.66  to  i.o)  of  tinc- 
ture of  opium  is  given  and  after  a  quarter  of  an  hour  from  15  to  60  grains 
(1.0  to  4.0)  of  ipecac,  depending  upon  the  age  of  the  patient  and  the  type  of 
the  infection,  are  taken.  The  drug  may  be  given  in  pill  form  or  suspended 
in  a  little  water  to  which  a  little  peppermint  or  anise  oil  has  been  added.  Should 
emesis  be  induced  the  dose  should  be  repeated  as  soon  as  the  stomach  is 
at  rest.  The  ipecac  may  be  given  for  considerable  periods,  the  dosage  being 
diminished  as  the  dysentery  becomes  less  marked  in  severity. 

Intestinal  antiseptics  may  be  employed  as  advised  in  the  treatment  of  chronic 
diarrhoeal  conditions  (see  p.  397),  but  are  usually  less  effective  than  the 
forms  of  treatment  described  above. 

Treatment  by  means  of  intestinal  irrigations  often  brings  about  good  results. 
The  apparatus  necessary  consists  of  a  fountain  syringe  to  which  a  long  rectal 
tube  of  soft  rubber  is  attached.  When  the  intestine  is  very  irritable  it  may  be 
wise  to  pass  a  soft  catheter  beside  the  tube  to  carry  off  the  return  flow  and 
prevent  distention  of  the  bowel.  Forcible  irrigation  is  contraindicated,  a 
gentle  flow,  the  receptacle  containing  the  fluid  to  be  used  being  held  at  a 
height  not  greater  than  three  or  four  feet  above  the  patient,  being  preferable. 
Careful  introduction  of  the  tube  is  necessary  and  a  skilled  hand  may  often 
succeed  in  passing  the  same  well  beyond  the  sigmoid  flexure.  The  discom- 
fort accompanying  its  passage  in  instances  of  severe  tenesmus  may  be  obviated 
by  the  insertion  of  a  cocaine — gr.  J  to  ^  (0.016  to  0.032) — and  iodoform — gr. 
viii  (0.5) — suppository  shortly  before  the  procedure.  The  quantity  of  the  irri- 
gation selected  may  be  from  one  to  two  gallons  (4  to  8  litres)  although  irri- 
gations so  large  in  amount  may  at  first  be  intolerable  to  the  patient,  we  may, 
by  beginning  with  small  quantities,  gradually  increase  until  the  bowel  becomes 
tolerant  and  the  patient's  discomfort  endurable.  The  insertion,  previous 
to  the  injection,  of  such  a  suppository  as  that  given  above  or  the  injection 
of  a  drachm  (4.0)  of  tincture  of  opium  in  a  little  starch  water  will  often 
render  the  subsequent  irrigation  well  borne.  The  temperature  of  the  irri- 
gation is  an  important  consideration,  cold  irrigations  being  indicated  in 
sthenic  cases  while,  when  stimulation  is  desirable,  higher  temperatures  are 
advisable.     Tepid  irrigations  are  seldom  employed. 

Various  solutions  have  been  employed  in  the  different  types  of  dysentery. 


DYSENTERY.  79 

In  the  simple  catarrhal  and  the  diphtheritic  forms  simple  cold  water,  or  hot 
saline  solution  may  be  employed.  Here  also  astringent  solutions  such  as 
alum  (2  percent.),  zinc  phenolsulphonate  (0.25  percent.),  silver  nitrate  (0.25 
percent.),  tannic  acid  and  salicylic  acid  (i  to  2  percent.),  silver-protein— 
protargol — (0.75  percent.)  are  of  use.  An  infusion  containing  45  grains 
(3.0)  of  ipecac  is  said  to  be  useful.  Those  particularly  indicated  in  bacillary 
dysentery  are  antiseptics,  silver  nitrate  and  protargol  in  the  strengths  given 
above,  methylthionine  hydrochloride  gr.  x  (0.66)  to  a  quart  (i  litre)  of  saturated 
solution  of  boric  acid,  potassium  permanganate  (0.025  percent.).  In  amoebic 
dysentery  an  approved  irrigation  is  of  quinine  sulphate,  i  to  5,000,  gradu- 
ally increased  to  2  to  1,000.  Mercury  bichloride  i  to  1,000  to  i  to  6,000  may 
be  used.  Such  irrigations  consisting  of  from  two  to  four  quarts  (2  to  4 
litres)  are  given  twice  a  day.  Recently  it  has  been  found  that  irrigations  of 
copper  sulphate  solution  of  a  strength  of  i  to  6 ,000  or  less  are  very  efl&cient. 
The  irrigations  are  given  twice  a  day,  and  the  colon  having  been  filled,  the 
fluid  is  retained  for  twenty  minutes  if  possible.  A  preliminary  cleansing  of 
the  gut  by  means  of  the  injection  of  sterile  water  is  advisable.  This  water 
should  be  allowed  to  drain  away  before  the  medicated  irrigation  is  given. 
Enemata  of  ice  water  are  also  useful  in  this  type  of  the  disease.  Hydrogen 
dioxide,  both  in  amoebic  and  bacillary  dysentery,  may  be  injected  per  rectum 
as  a  parasiticide. 

Cases  of  tropical  dysentery  are  reported  as  being  favorably  influenced  by 
drinking  sulphur  waters,  and  sulphm"  in  connection  with  pulvis  ipecacuanhas 
et  opii  has  been  suggested  for  internal  administration;  15  or  20  grains 
(i.o  to  1.33)  of  the  former  and  five  grains  (0.33)  of  the  latter  may  be  given 
every  four  hours.  In  this  form  of  dysentery  excellent  results  are  said  to 
follow  the  administration  of  the  fluid  extract  of  cortex  granati  and  of  aplopap- 
pus  balayhuen,  a  South  American  drug  and  one  used  there  in  dysentery. 

In  dysentery  of  the  chronic  type  pure  olive  oil  may  be  tried.  It  is  said  to 
act  as  a  cholagogue,  and  to  decrease  the  number  of  bowel  movements  and 
the  tendency  to  intestinal  fermentation  and  putrefaction. 

Much  research  has  been  carried  out  in  the  attempt  to  elaborate  an  anti- 
dysenteric  serum  and  while  in  some  instances  favorable  reports  have  been 
made  of  the  results  of  these  endeavors,  as  yet  we  have  no  specific  serum 
which  may  be  relied  upon. 

Before  concluding  it  is  well  to  mention  the  surgical  management  of  chronic 
dysenteric  conditions.  This  consists  in  the  formation  of  an  artificial  anus 
through  which  the  bowel  may  be  irrigated.  It  has  been  suggested  that  the 
appendix,  being  opened  and  fastened  to  the  edges  of  a  colostomy  wound,  may 
be  used  in  this  way.  When  rectal  ulcers  exist  in  subacute  or  chronic  instances 
they  may  be  opened  under  anaesthesia,  scraped  and  touched  with  caustic. 
They  then  should  be  irrigated  with  warm  normal  saline  solution  and,  when 


8o  THE    INFECTIOUS    DISEASES. 

healed,  the  employment  of  irrigations  of  silver  nitrate,  i  to  500  to  i  to  250,  is 
advised. 

EPIDEMIC  GANGRENOUS  PROCTITIS. 

Definition.  An  acute  infectious  disease  characterized  by  rapidly  pro- 
gressing ulceration  of  the  rectum  resulting,  in  certain  instances,  in  prolapse 
and  gangrene. 

Etiology.  This  affection  occurs  in  certain  parts  of  Central  and  South 
America,  the  Philippines  and  in  islands  of  the  Malay  Archipelago.  Children 
are  more  frequently  attacked  than  adults  and  in  Northern  South  America 
the  latter  are  not  affected.  The  disease  is  favored  by  unsanitary  conditions 
and  malnutrition,  and  marked  humidity  is  probably  necessary  to  its  occurrence. 
It  has  been  attributed  to  the  eating  of  unripe  maize  but,  since  the  affection 
has  been  reported  in  regions  vi^here  this  cereal  is  unknown,  this  cannot 
be  held  responsible  for  all  cases.  The  essential  factor  in  the  aetiology  of 
epidemic  gangrenous  proctitis  is  probably  a  micro-organism,  although  possibly 
not  a  specific  one,  since  by  some  it  is  not  regarded  as  a  distinct  disease  but 
is  considered  merely  a  dysentery  of  severe  type,  the  lesions  of  which  are,  for 
some  unknown  reason,  confined  to  the  colon. 

Pathology.  The  typical  lesions  of  this  disease  consist  of  deep  ulcera- 
tions of  the  rectal  mucous  membrane  occurring  low  in  the  viscus  between  the 
two  sphincters  or  higher  than  this  point,  even  involving  the  lining  of  the 
sigmoid  flexure,  and  covered  with  a  pseudo-membranous  exudation.  In 
the  severest  forms  of  the  affection  there  is  rectal  prolapse  with  gangrene 
of  the  extruded  portion. 

Symptoms.  The  invasion  of  the  disease  is  characterized  by  burning 
and  pruritus  of  the  anal  region  followed  by  symptoms  resembling  those  of 
dysentery.  The  dejecta  are  faecal  at  first  and  very  foul,  later  they  are  mixed 
with  mucus  and  finally  consist  merely  of  blood  and  mucus  which  runs  slug- 
gishly but  constantly  from  the  anus.  Tenesmus  is  present,  progressive 
weakness,  even  to  collapse,  is  manifested  and  there  are  pronounced  cerebral 
symptoms — delirium  or  coma.  Death  in  convulsions  may  supervene,  or, 
the  patient  surviving,  rectal  prolapse  takes  place,  the  prolapsed  portion  of  the 
gut  soon  sloughing. 

The  differential  diagnosis  from  dysentery  may  be  made  by  means  of  proc- 
toscopic examination.  The  prognosis  of  the  disease  is  distinctly  unfavorable 
but  even  the  most  severely  affected  patients  sometimes  recover.  After  slough- 
ing of  the  prolapsed  rectum  recovery  has  been  observed,  the  process  being 
analogous  to  that  which  takes  place  in  a  sloughing  intussusception  which 
heals  spontaneously. 

Treatment.     Taking    into  consideration  that  this  affection  is  probably 


HILL    DIARRHCEA.  8 1 

due  to  an  infectious  process  localized  in  the  rectum,  the  indication  for  treat- 
ment would  seem  clear,  namely,  to  render  this  viscus  as  antiseptically  clean 
as  possible.  For  this  purpose  injections  of  mercury,  bichloride  solution 
(i  to  10,000  to  I  to  6,000),  of  hydrogen  dioxide,  of  weak  creolin  solution, 
of  silver  vitellin  (20  percent.),  etc.,  may  be  employed.  The  prolapsed  rectum 
should  not  be  reduced  but  should  be  cleansed  and  kept  dusted  with  bismuth 
subgallate  (dermatol),  thymol  iodide  (aristol)  or  other  similar  powder.  Sur- 
gical procedures  are  indicated  when  gangrene  takes  place. 

HILL  DIARRHCEA. 

Definition.  An  acute  diarrhoeal  disease  characterized  by  whitish  stools 
occurring  in  the  morning  and  a  tendency  to  abdominal  tympanites. 

.etiology.  This  disease  is  seen  in  the  mountainous  regions  of  British 
India  in  persons  who  are  accustomed  to  residence  in  the  tropics  but  have 
gone  from  lowland  to  highland  districts. 

Marked  humidity  and  a  high  altitude  seen  to  be  the  chief  predisposing 
factors  in  its  occurrence.     Its  specific  cause  has  not  been  determined. 

Pathology.  The  pathogenesis  of  this  disease  is  probably  based  upon  a 
transient  disorder  or  cessation  of  the  hepatic  and  pancreatic  functions  which 
may  be  the  result  of  the  effort  of  an  impaired  digestion  to  accommodate  itself 
to  unusual  meteorologic  conditions.  By  certain  observers  it  is  considered 
to  be  induced  by  the  effect  of  the  unusual  cold  and  dampness  of  the  early 
morning  of  tropical  mountainous  climates  upon  the  atonic  colon  which  is 
likely  to  be  met  in  those  who  have  lived  in  hot  countries  for  considerable 
periods  of  time. 

Symptoms.  The  disease  is  evidenced  by  disordered  digestive  function  and 
the  appearance  of  a  morning  diarrhoea.  The  stools  increase  progressively 
in  number  until  there  are  8  or  10  daily,  the  first  appearing  about  daybreak, 
the  last  about  noon  or  shortly  before  this  time.  The  dejections  are  colorless, 
of  large  size,  pasty  or  frothy,  and  of  sickish  odor.  Pain  is  not  marked  though 
there  may  be  slight  discomfort  referred  to  the  region  of  the  colon.  Abdom- 
inal cramps  and  tenesmus  are  conspicuously  absent.  Abdominal  distention 
is  a  prominent  symptom  and  there  is  manifest  digestive  disturbance  charac- 
terized particularly  by  discomfort  after  meals.  This  disease  is  analogous 
to  sprue  but  differs  from  the  latter  in  its  tendency  to  recovery  after  a  few 
weeks.  Certain  cases  may  progress  and  terminate  in  true  psilosis,  while 
others  persist  until  the  patient  returns  to  a  lower  altitude. 

Treatment   consists  in  combating  the  tendency  to  digestive  disorder  by 

means  of  a  diet  of  milk  and  other  easily  digestible  fluids  and  by  keeping  the 

patient  in  bed  until  the  noon  hour.     Cholagogues,  especially  calomel  in  small 

doses,  are   indicated  and  the  administration  of  pilocarpine  hydrochloride, 

6 


82  THE    INFECTIOUS    DISEASES. 

^  to  J  of  a  grain  (0.008  to  0.022),  is  suggested  with  a  view  to  increasing  the 
pancreatic  secretion. 

Artificial  digestive  ferments  particularly  pancreon  and  pancreatin  may 
prove  useful.  Cases  which  are  uncontrollable  by  ordinary  means  must 
be  sent  to  low-lying  districts. 

SPRUE. 

Synonym.     Psilosis. 

Definition.  A  disease  of  tropical  countries  characterized  by  a  catarrhal 
inflammation  of  the  entire  digestive  tract  which  results  finally  in  glandular 
atrophy  and  which  is  evidenced  clinically  by  sore  mouth,  diarrhoea  and  dis- 
tention of  the  intestines  with  gas. 

.Etiology.  This  disease  is  common  to  all  tropical  climates  and  prevails 
particularly  in  India,  Southern  China  and  the  Malayan  Archipelago  Author- 
ities differ  as  to  whether  sprue  is  a  specific  bacterial  infection  or  originates 
secondarily  to  the  diarrhoeal  and  other  wasting  diseases,  malaria,  etc.,  which 
are  common  in  the  tropics.  The  fact  that  no  bacterial  cause  for  the  disease 
has  yet  been  isolated  is  against  the  former  hypothesis.  Various  micro- 
organisms and  intestinal  parasites  have  been  considered  as  causes  of  the  affec- 
tion but  their  occurrence  is  probably  a  coincidence  or  they  are  present  as  a 
result  of  preceding  morbid  conditions.  The  strongyloides  intestinalis,  the 
amoeba  coli  and  several  varieties  of  bacilli  intermediate  between  the  colon 
bacillus  and  the  bacillus  of  enteric  fever  are  frequently  found.  Predisposing 
factors  to  the  incidence  of  sprue  are  fatigue  and  over-exertion,  pysemic  con- 
ditions, the  puerperal  state,  nephritis,  and  in  fact,  any  influence  which  tends  to 
vitiate  the  bodily  power  of  resistance.  The  affection  usually  shows  itself 
during  tropical  residence  but  may  not  occur  until  the  patient  has  returned 
to  temperate  regions;  it  may  remain  inactive  in  the  system  for  years. 

Pathology.  The  changes  found  after  death  from  sprue  consist  of 
atrophy  of  the  mucous  membrane  and  glandular  structures  of  the  small 
intestine.  The  latter  may  be  entirely  destroyed,  but  while  the  intestinal 
wall  is  greatly  thinned,  the  peritonaeal  coat  is  unaffected.  The  agminated 
glands  may  be  swollen  or  ulcerated  and  dysenteric  ulcerations  may  be  present 
in  the  large  intestine.  The  mesenteric  and  subcutaneous  fatty  tissue  has 
wholly  disappeared.  The  parenchyma  of  the  liver,  pancreas  and  kidneys 
may  be  the  seat  of  an  inflammatory  process  or  of  localized  fatty  degeneration. 
The  mucous  membrane  of  the  mouth  is  eroded,  ulcerated  and  cracked. 

Symptoms.  The  typical  manifestations  of  sprue  are  sore  mouth,  irreg- 
ular diarrhoea  and  tympanites.  The  tongue  is  seldom  .coated,  it  is  yellowish 
in  color,  pointed  and  shrunken  and  tiny  aphthous  ulcers  are  often  present 
at  its  edge  and  upon  its  ventral  surface.     These  lesions  may  also  be  observed 


SPRUE.  83 

upon  the  hard  and  soft  palates.  The  dorsum  of  the  tongue  is  dry  and  shining, 
or  it  may  be  the  seat  of  very  shallow  erosions  which  may  unite  to  result  in  a 
serpigenous  formation.  Fissiires  may  be  present  and  the  patient  complains 
of  buccal  soreness  which  is  increased  upon  taking  salty  or  highly  seasoned 
food.  Pain  on  swallowing  may  be  noted,  showing  that  the  oesophagus  is 
probably  in  a  condition  analogous  to  that  of  the  tongue. 

Emaciation  is  marked  and  the  abdomen  is  tensely  distended  and  tympanitic. 
Eructations  are  frequent  and  either  gas  or  watery  fluid  may  make  its  appear- 
ance in  the  throat  as  a  result  of  this  symptom.  The  appetite  may  be  excessive 
or  entirely  lost.  Nausea  and  vomiting  uninfluenced  by  eating  may  occur. 
Gastric  discomfort  and  pain  often  are  associated  with  the  flatulence. 

The  diarrhoea  is  a  characteristic  manifestation,  the  movements  varying 
from  one  to  a  dozen  in  the  24  hours.  They  are  large,  acid,  foetid,  white  and 
frothy,  resembling  whitewash,  and  are  usually  unaccompanied  by  pain.  Micro- 
scopical examination  reveals  bits  of  the  mucous  lining  of  the  gut,  micro- 
organisms and  perhaps  a  small  number  of  red  blood-cells. 

The  patient  becomes  rapidly  weak  and  emaciated  as  a  result  of  the  im- 
pairment of  assimilation  due  to  the  interference  with  the  action  of  the  intes- 
tine and  the  inability  to  retain  food.  The  skin  is  sallow  and  yellowish  and 
secondary  anaemia  is  marked,  the  leucocytes  are  not  increased  in  number. 
Attacks  of  tetany  have  been  noted.  The  course  of  the  disease  is  chronic  with 
no  tendency  toward  spontaneous  recovery,  although  temporary  improvement 
may  be  observed  from  time  to  time.  The  patient  may  recover  unless  the 
mucous  lining  of  the  intestine  is  so  atrophied  as  to  render  suflacient  assimila- 
tion impossible.  The  affection  usually  lasts  for  a  year  or  two  but  a  much 
more  protracted  course  is  not  rare. 

Treatment  is  principally  dietetic.  The  patient  should  be  kept  in  bed 
and  fed  upon  frequently  repeated  small  quantities  of  milk.  As  rapidly 
as  possible  the  amount  of  milk  should  be  increased.  Whether  the  patient  is 
receiving  too  much  is  indicated  by  its  appearance  undigested  in  the  stools 
and  increase  in  the  soreness  of  the  mouth.  In  favorable  cases  after  a  month 
or  more  the  buccal  symptoms  and  the  diarrhoea  will  begin  to  disappear. 
Successes  have  been  reported  to  have  followed  a  diet  entirely  of  meat  or 
meat  juice,  and  certain  observers  consider  the  use  of  minced  meat,  five  ounces 
(160.0)  three  times  a  day  as  important.  Antiscorbutic  treatment  has  been 
advised,  and  a  fruit  diet,  particularly  a  regimen  of  berries,  is  said  to  have  pro- 
duced rather  remarkable  cures.  Strawberries  are  reputed  to  have  achieved 
cure  in  obstinate  instances  of  the  disease. 

In  the  control  of  the  diarrhoea  the  intestinal  antiseptics,  particularly  the 
salts  of  bismuth,  the  naphtholate  and  the  tetraiodophenolphthaleinate,  may 
be  employed  and,  when  convalescence  has  become  established,  general  tonic 
treatment  by  means  of  iron,  arsenic  and  strychnine  is  indicated. 


84  THE    INFECTIOUS   DISEASES. 

THE   PLAGUE. 

Synonyms.  Bubonic  Plague;  Black  Death;  Malignant  Adenitis;  The 
Pest. 

Definition.  An  epidemic  contagious  febrile  disease  characterized  by 
swelling  and  inflammation  of  the  lymph  glands  and  haemorrhages  into  the 
skin  and  mucous  membranes. 

.etiology.  The  disease  is  endemic  in  India  and  from  time  to  time  epi- 
demics have  appeared  in  various  European  countries.  Patients  suffering 
from  the  disease  have  been  brought  to  New  York  and  instances  of  the  affection 
have   been  observed  amongst  the  Chinese  in  San  Francisco. 

The  plague  is  most  common  during  the  hot  months  and  is  seldom  seen  in 
individuals  beyond  middle  life.  The  chief  predisposing  factor  is  lack  of 
proper  hygiene,  the  infection  being  usually  met  in  crowded  and  filthy  quarters 
and  amongst  the  poor  and  ill-nourished. 

The  specific  cause  of  the  affection  is  the  bacillus  pestis  which  was  discovered 
in  1894  by  Yersin  and  Kitasato. 

Transmission  and  Modes  oj  Infection.  The  contagium  of  bubonic  plague 
may  enter  the  body  through  the  respiratory  or  digestive  tracts  or  through 
abrasions  of  the  skin  and  is  found  in  the  blood  of  patients  and  in  the  pus 
from  the  suppurating  glands.  It  is  given  off  in  the  faeces,  urine  and  sputum 
and  contaminates  clothing,  bed  linen,  apartments  and  the  like.  It  may  be 
carried  by  fleas  and  other  insects  and  by  rats,  mice,  dogs,  etc. 

Pathology.  The  skin  and  the  digestive  tract  are  the  seat  of  punctate 
extravasations  of  blood;  these  are  also  found  upon  the  serous  membranes  and 
upon  the  capsules  of  the  viscera.  The  latter  and  the  central  nervous  system 
are  congested.  The  spleen  is  enlarged.  In  the  bubonic  type  of  the  disease 
the  lymph  glands,  particularly  those  of  the  axillae  and  groins,  are  swollen  and 
inflamed  and  often  undergo  haemorrhage,  suppuration  and  necrosis.  The 
peri-glandular  tissue  may  be  involved  in  similar  changes.  In  these  glands 
the  bacillus  pestis  is  found  and,  after  suppuration  has  taken  place,  with  it 
other  pathogenic  bacteria  are  associated.  The  lymph  system  is  affected  in  all 
types  of  the  disease  but  in  the  bubonic  form  a  particular  set  of  glands  will  be 
chiefly  involved.  In  the  pneumonic  variety  the  bronchial  lymph  nodes  are 
especially  affected  and  areas  of  broncho-pneumonia  exist  in  the  lungs.  Here 
the  bacilli  are  found  in  the  sputum. 

Symptoms.  The  disease  occurs  in  two  main  types,  i.  pestis  minor  and  2. 
pestis  major.  The  latter  is  met  in  three  varieties:  a.  The  bubonic  form. 
h.  The  septicaemic  form.       c.  The  pneumonic  form. 

Pestis  minor,  abortive  or  ambulant  plague,  is  seen  usually  just  before  or  at 
the  termination  of  an  epidemic.  The  patient  is  seldom  very  ill  but  is  a  great 
danger  to  the  community  since  his  excreta  contain  the  contagium.     The 


THE    PLAGUE.  85 

attack  lasts  several  days  and  is  characterized  by  mild  fever,  and  swelling  and 
tenderness  of  the  inguinal  glands.     Suppuration  may  occur. 

Pestis  Major.  The  incubation  period  is  from  three  to  seven  days;  during 
the  day  or  two  before  the  onset  of  the  disease  the  patient  may  complain  of 
indefinite  malaise,  dizziness  and  general  pains.  The  invasion,  which  may  be 
without  prodromata,  is  marked  by  a  chill  or  chilly  feelings  followed  by  a  rapid 
rise  in  temperature  to  104°  to  106°  F.  (40°  to  41.1°  C).  The  pulse  is  rapid, 
and  some  nervous  symptoms  and  prostration  are  marked  and  the  patient 
may  die  in  collapse.  Should  he  survive,  about  the  third  to  the  fifth  day  the 
glandular  swellings  appear,  the  inguinal  lymph  nodes  being  affected  in  the 
majority  of  cases.  These  become  red  and  tender  and  may  resolve,  suppu- 
rate or  become  gangrenous.  Petechial  haemorrhages  take  place  into  the  skin 
and  there  may  be  bleeding  from  the  various  mucous  membranes,  gastric, 
intestinal,  pulmonary,  etc. 

In  the  septicemic  type  of  the  infection  the  bacilli  are  found  in  the  blood 
stream,  the  patient  is  profoundly  poisoned  and  is  likely  to  die  before  the 
glandular  swelling  takes  place.  The  typhoid  condition  is  rapidly  developed 
and  haemorrhages  are  common. 

The  pneumonic  form  of  the  disease  is  sudden,  in  onset  with  a  chill,  rise  in 
temperature,  cough  and  pain  in  the  chest  resembhng  those  of  lobar  pneumonia. 
Physical  signs  of  pulmonary  consolidation  may  be  obtained,  the  sputum  is 
mucoid  and  contains  blood  and  the  bacillus  pestis  in  large  numbers.  This 
form  of  plague  is  very  fatal,  the  patient  seldom  surviving  more  than  three 
days. 

The  diagnosis  may  be  made  upon  the  appearance  of  the  glandular  tumors 
and  upon  the  occurrence  of  the  bacillus  in  the  excreta  and  blood. 

The  prognosis  is  markedly  unfavorable;  from  70  to  90  percent,  of  those 
afflicted  usually  perish.  The  septicaemic  and  pneumonic  varieties  are  espe- 
cially fatal.  Suppuration  of  the  buboes  is  a  favorable  sign  while  the  occur- 
rence of  haemorrhages  is  the  contrary. 

Treatment.  Prophylaxis  consists  in  the  establishment  of  proper  sanitary 
conditions,  the  extermination  of  rats,  isolation  of  patients,  careful  disinfection 
of  their  excretions,  of  bed  clothing,  apartments,  etc.,  and  cremation  of  the  dead. 

Much  can  be  done  toward  immunization  since  the  work  of  Haffkine  and 
Yersin  in  the  elaboration  of  protective  sera.  Of  Haffkine's  serum  the  dose  is 
about  38  minims  (2.5)  and  by  its  use,  according  to  reports,  the  death  rate  may 
be  markedly  diminished  and  epidemics  controlled. 

The  treatment  of  the  attack  is  to  a  great  extent  symptomatic.  At  the  onset 
the  bowels  should  be  opened  by  means  of  fractional  doses  of  calomel  followed 
by  a  saline.     The  fever  may  be  controlled  by  cool  sponge  baths. 

The  coal  tar  antipyretics  should  not  be  given  on  account  of  their  depressing 
effect  upon  the  heart.     For  the  nervous  symptoms  the    bromides    may  be 


86  THE    INFECTIOUS    DISEASES. 

administered  but  for  these  and  the  pain  the  hypodermatic  exhibition  of  mor- 
phine often  becomes  necessary.  For  the  tendency  to  heart  weakness  and 
collapse  stimulants  such  as  ammonia,  alcohol,  strychnine  and  camphor  dis- 
solved in  aether  or  sterile  olive  oil,  are  indicated.  The  glandular  swellings 
may  be  treated  by  means  of  cold  applications,  or  poulticed.  When  the  pres- 
ence of  pus  is  manifest  they  should  be  promptly  incised  and  drained.  The 
iiyection  into  the  buboes  of  mercury  bichloride  has  been  employed  with 
good  results. 

Phenol  is  recommended  and  has  given  excellent  results.  It  is  given  in 
doses  of  12  grains  (0.8)  every  two  hours  (144  grains — 9.6  daily)  and  when 
taken  well  diluted  causes  no  disturbance  except  carboluria. 

Much  research  has  been  conducted  in  the  hope  of  producing  an  effective 
antiplague  serum  and  at  least  two  antitoxins  have  been  elaborated  which 
are  useful.  That  of  Yersin  seems  to  be  considered  more  effective  than  that 
of  Haffkine.  The  former  is  considered  by  certain  observers  to  be  of  great 
value.  Its  action  is  said  to  be  bactericidal,  as  evidenced  by  the  degenera- 
tion induced  in  the  bacilli,  and  antitoxic  as  well.  In  order  to  achieve  the 
best  results  the  serum  should  be  given  in  large  doses  early  in  the  disease,  both 
intravenously  and  under  the  skin  of  the  lymphatic  area  which  drains  toward 
the  bubo.  In  mild  instances  of  the  disease  the  latter  method  will  often  suflSce 
but  in  marked  infections  the  combined  method  is  necessary,  the  beginning 
dose  being  about  5  to  10  drachms  (20.0  to  40.0),  the  intravenous  dose 
varying  with  the  severity  of  the  intoxication.  No  evil  results  are  reported 
as  due  to  this  treatment. 

CLIMATIC  BUBO. 

Synonyms.    Tropical  Bubo;  Tropical  Adenitis. 

This  affection  consists  of  a  non-venereal  subacute  inflammation  of  the 
inguinal  glands  associated  with  a  remittent  fever  lasting  several  weeks.  It 
is  observed  on  the  tropical  coasts  of  Asia  and  Africa,  in  the  Philippines 
and  the  Malayan  Archipelago,  and  in  the  West  Indies. 

It  is  prone  to  affect  persons  living  in  close  association  amid  unhealthy 
surroundings  and  is  met  in  epidemics.  Its  chief  importance  consists  in  the 
fact  that  it  may  be  mistaken  for  pestis  minor  from  which  it  is  bacteriologically 
entirely  distinct.  Its  aetiology  is  not  definitely  known  but  it  has  been  consid- 
ered to  be  a  bacterial  infection  which  effects  an  entrance  by  means  of  abra- 
sions upon  the  legs  or  about  the  genitalia  or  by  means  of  the  stings  of  insects. 
It  has  also  been  considered  as  occurring  secondarily  to  dysentery  and  chronic 
malaria. 

Symptoms.  These  consist  of  unilateral  or  bilateral  inflammation  of  the 
inguinal  glands  or  those  about  the  saphenous  opening,  preceded  by  a  chill, 


DIPHTHERIA.  87 

general  pains  and  malaise.  A  remittent  fever  follows.  The  glands  increase 
in  size  for  from  three  to  four  weeks  when  the  fever  subsides  by  lysis.  The 
glandular  tumors  remain  for  several  months  and  slowly  resolve.  In  a  small 
percentage  of  cases  the  tissues  about  the  glands  become  involved  and  sup- 
puration takes  place,  the  constitutional  symptoms  under  such  conditions 
are  marked.  If  not  opened  the  abscesses  tend  to  spread  and  finally  burst 
discharging  pus.  The  discharge  continues  for  varying  periods,  finally  ceasing 
and  leaving  behind  sluggish  painful  ulcers. 

Treatment.  This  is  entirely  symptomatic  and  surgical.  Until  sup- 
puration occurs  the  buboes  should  receive  inunctions  of  unguentum  Crede, 
10  percent,  ichthyol  or  compound  iodine  ointment.  If  they  subside  without 
pus  formation,  in  their  declining  stages  inunctions  of  unguentum  hydrargyri 
and  snug  bandaging  are  indicated.  As  soon  as  the  presence  of  pus  is  apparent, 
free  incision,  drainage  and  dressing  with  antiseptics  are  necessary.  The 
ulcers  which  follow  suppuration  should  be  treated  in  accordance  with  surgical 
principles.  It  is  said  that  calomel  dusted  over  their  surfaces  will  relieve  the 
pain. 

DIPHTHERIA. 

Synonyms.     Membranous  Croup;  Angina  Malignum;  Putrid  Sore  Throat. 

Definition.  An  acute  infectious  febrile  disease  characterized  by  inflam- 
mation and  the  formation  of  a  false  membrane  in  the  upper  air  passages, 
particularly  in  the  pharynx.  The  specific  disease,  diphtheria,  is  the  result 
of  infection  with  the  Klebs-Loffler  bacillus.  To  the  affections  of  similar 
clinical  appearance,  but  of  usually  milder  course,  which  are  not  due  to  this 
bacillus,  the  terms  diphtheroid  and  pseudo-diphtheria  are  applied.  Diph- 
theria has  been  known  since  the  time  of  Galen  and  from  time  to  time  has 
occurred  epidemically.  Its  specific  nature,  however,  was  not  distinctly 
proven  until  the  discovery  of  the  hacilhls  diphthericB. 

.etiology.  The  disease  occurs  chiefly  in  children  and  is  rare  after  the 
age  of  16  years.  It  is  seldom  seen  in  very  young  infants  especially  in  those 
who  are  breast  fed.  It  is  predisposed  to  by  the  presence  of  nasal  or  pharyngeal 
catarrh,  a  poorly  cared  for  mouth  and  teeth,  adenoids  and  enlarged  tonsils, 
and  is  most  prevalent  in  the  cold  and  damp  months.  It  appears  rather  amongst 
unsanitary  surroundings  than  in  healthy  districts,  although  severe  epidemics 
have  been  observed  in  the  country.  Bad  drainage  and  emanations  of  se\Aer- 
gas  have  never  been  proven  to  have  any  direct  influence  upon  the  incidence 
of  the  disease  and  when  the  infection  occurs  where  these  factors  are  present, 
save  in  so  far  as  residence  in  places  exposed  to  their  influence  is  likelv  to 
depreciate  the  general  health  and  lessen  the  powers  of  resistance,  they  are 
not  causative. 


88  THE    INFECTIOUS    DISEASES. 

The  specific  cause  of  diphtheria  is  the  Klebs-Loffler  bacillus,  a  non-motile, 
short,  slightly  bent  bacterium  with  rounded  ends.  This  organism  may  be  found 
in  the  false  membranes  of  the  disease  and  in  its  growth  produces  a  poisonous 
substance  which  is  responsible  for  the  constitutional  symptoms.  With  the 
diphtheria  bacillus  other  pathogenic  bacteria  are  often  associated  which  may 
be  held  responsible  for  the  purulent  inflammations  which  frequently  com- 
plicate the  disease.  Of  these  the  streptococcus  pyogenes  is  the  most  important. 
It  is  an  interesting  fact  that  the  diphtheria  bacillus  may  be  found  in  the  mouths 
of  healthy  persons  in  whom  it  causes  no  symptoms.  This  fact  may  be  due 
to  a  lack  of  virulence  on  the  part  of  these  bacilli,  a  natural  immunity,  or  suffi- 
cient power  of  resistance  upon  the  part  of  the  individual  to  render  them 
inert. 

The  contagium  is  transmitted  upon  the  air  or  by  means  of  ingested  sub- 
stances and  may  be  received  from  the  membranous  exudate  or  nasal  or  pharyn- 
geal secretions  of  patients  either  actively  ill  or  convalescent  from  the  disease 
or  from  persons  who  have  come  in  contact  with  sufferers.  The  disease  is 
markedly  contagious  for  the  distance  of  a  few  feet  but  fortunately  its  con- 
tagium is  not  very  diffusible,  consequently  it  is  quite  possible  to  confine 
it  to  a  single  room.  The  contagious  material  is  resistant  and  of  considerable 
viability  and  may  remain  upon  clothing,  etc.,  for  a  number  of  months. 

Previously  it  has  been  believed  that  diphtheria  might  be  conV^eyed  to  man 
by  means  of  contagion  from  cats,  calves  and  fowls  which  were  affected  by  a 
disease  of  identical  causation,  but  it  has  been  proven  that  the  diphtheria  of 
these  animals  is  a  different  affection  and  is  not  communicable  to  human 
beings. 

Pathology.  The  characteristic  pseudo-membrane  of  diphtheria  may  be 
found  in  various  situations.  Of  these  the  throat,  the  tonsils,  pharynx  and 
larynx,  including  the  epiglottis,  are  most  frequently  affected.  The  mem- 
brane commonly  occurs  upon  the  nasal  mucous  membrane,  in  the  trachea 
and  in  the  bronchi.  Less  frequent  situations  are  the  oesophagus,  the  stomach, 
the  duodenum,  the  vagina,  the  vulva,  the  ear  and  the  conjunctiva.  The 
nasal  accessory  sinuses  may  be  involved  and  the  process  may  extend  to  the 
middle  ear  through  the  Eustachiun  tube. 

The  membrane  is  first  yellowish-white  in  color,  later  becoming  grayish. 
Early  in  the  disease  it  is  firmly  attached  to  the  underlying  mucous  membrane 
and,  when  detached,  leaves  abrasions,  later  it  is  softer  and  more  easily  re- 
moved. In  extreme  instances  the  mucosa  beneath  may  be  gangrenous.  The 
adjacent  lymph  glands  are  enlarged  and  the  salivary  glands  may  be  swollen. 

Similar  membranous  inflammations  may  occur  in  scarlatina,  measles, 
pertussis  and  enteric  fever.  These  are  usually  the  result  of  streptococcus 
infection  and  are  termed  diphtheroid. 

The  diphtheritic  membrane  is  the  result  of  a  degenerative  necrosis  of  the 


DIPHTHERIA.  89 

mucous  membrane.  The  epithelial  cells  are  infiltrated  with  fibrin  and 
leucocytes,  necrose,  and  then  undergo  a  hyaline  transformation  and  coagula- 
tion. To  this  process  the  term  "coagulation-necrosis"  has  been  applied. 
The  membrane  histologically  is  composed  of  coagulated  fibrin,  necrotic  tissue 
and  the  diphtheria  bacilli. 

The  heart  is  frequently  the  seat  of  fatty  degeneration  which  may  precede 
a  hyaline  change  in  the  heart  muscle.  Endocarditis  may  be  present  with 
vegetations  in  which  the  bacilli  are  found.  This  latter  complication,  with 
pericarditis,  is  rare. 

Broncho-pneumonia  is  often  present;  the  kidneys  are  the  seat  of  an  acute 
degeneration  or  a  true  acute  nephritis.  .  The  liver  and  spleen  are  softened 
and  degenerated  (cloudy  swelling). 

Symptoms.  The  incubation  is  usually  two  or  three  days,  rarely  as  long 
as  a  week.  The  onset  is  marked  by  chills,  or,  in  children,  a  convulsion,  fol- 
lowed by  a  rise  in  temperature;  there  are  headache,  bodily  pains,  nausea, 
vomiting  and  prostration,  but  in  the  mild  types  of  the  disease  these  symptoms 
may  be  very  slight.  The  temperature  is  not  a  marked  feature;  it  rises  to 
102°  to  104°  F.  (37.8°  to  40°  C).  The  pulse  is  rapid — 120  to  140 — and  is 
usually  small  and  feeble.     Cerebral  symptoms  are  infrequent. 

In  the  pharyngeal  type  there  is  complaint  of  sore  throat  and  difiiculty  in 
swallowing.  The  pharynx  and  tonsils  are  inflamed  and  swollen  and  upon 
the  latter  there  are  yellowish  spots  which  gradually  enlarge,  becoming  grayish 
in  color,  until  by  the  third  or  fourth  day  the  tonsils  are  entirely  covered  and  the 
pillars  of  the  fauces  and  the  soft  palate  may  be  involved  to  such  an  extent 
that  the  opening  of  the  pharynx  may  be  wholly  occluded.  The  cervical  glands 
are  swollen.  In  the  ordinary  infection  the  patient  is  not  markedly  poisoned 
and  the  symptoms  soon  abate.  In  about  a  week  or  ten  days  the  glandular 
swellings  have  disappeared  with  the  false  membrane,  leaving  the  pharynx 
clean,  the  temperature  falls  and  the  patient  is  convalescent. 

In  nasal  diphtheria  the  onset  is  marked  by  the  usual  constitutional  mani- 
festations and  an  increased  nasal  discharge  which  irritates  and  often  exco- 
riates the  upper  lip.  The  glands  beneath  the  angle  of  the  mandible  are  swollen 
and  indurated.  This  enlargement  is  characteristic  and  is  probably  due  to 
the  fact  that  the  nasal  mucosa  is  particularly  rich  in  lymphatics.  Many 
instances  of  nasal  diphtheria  are  of  severe  type  with  marked  constitutional 
symptoms  and  antral,  aural  or  ocular  complications  are  frequent.  A  peculiar 
form  is  sometimes  met  in  which  constitutional  manifestations  are  absent; 
the  nostrils  are  occluded  by  typical  membranes  in  which  the  bacilli  are  present 
but  the  infection  is  characterized  by  a  benign  course. 

Laryngeal  diphtheria  or  membranous  croup  is  characterized  by  a  laryngeal 
cough  at  the  onset  and  by  the  gradual  development  of  obstruction.  The 
latter   may,  however,  appear  suddenly  at  night.     The  respiration  is  rapid 


90 


THE    INFECTIOUS    DISEASES^ 


and  diflScult,  the  expiration  particularly  being  interfered  with,  the  abdomen 
and  lower  thorax  are  retracted  in  inspiration  and  the  mucous  membranes 
and  extremities  become  cyanotic  from  lack  of  oxygen.  The  patient  becomes 
restless  and  may  fall  into  a  semi-coma  and  die  of  asphyxia.  In  milder  instances 
the  paroxysm  may  last  but  a  short  time  and  the  patient  will  gradually  become 
quiet.  The  attack  is,  however,  likely  to  be  repeated  during  the  following 
night.  At  times  relief  will  follow  the  coughing  up  of  the  membrane,  in  part 
or  as  a  whole.  The  constitutional  symptoms  are  often  not  marked  but 
when  there  is  an  accompanying  pharyngeal  membrane  the  opposite  is  usually 
the  case. 

Membranous  croup  occurs  in  two  varieties,  the  clinical  appearances  and 
symptoms  of  which  are  so  similar  as  to  prevent  their  differentiation  except 
by  bacteriological  examination.  Cultures  alone  will  determine  whether 
the  affection  is  due  to  the  streptococcus  or  to  the  diphtheria  bacillus. 

Diphtheria  in  other-  parts  is  rather  infrequent  but  the  inflammation  may 
affect  the  conjunctiva,  either  primarily  or  by  extension  through  the  lacry- 
mal  duct,  the  skin,  especially  about  the  lips  and  nostrils  and  the  external 
auditory  meatus  by  extension  from  the  middle  ear.  The  genitals  may  be 
involved,  whence  the  inflammation  may  spread  to  the  surrounding  skin,  and 
diphtheritic  inflammations  may  occur  in  open  wounds  which  have  been  infected 
by  the  bacillus. 

The  symptoms  of  constitutional  infection  in  mild  infections  are  not  marked. 
In  more  severe  instances,  three  or  four  days  after  the  onset,  the  patient's  con- 
dition becomes  one  of  great  weakness,  the  heart  action  is  feeble  and  cerebral 
symptoms  are  present.  At  this  time  there  is  great  danger  of  death  from 
paralysis  of  the  heart.  In  other  patients  the  constitutional  symptoms  are 
prominent  from  the  beginning,  the  temperature  is  high  and  the  evidence 
of  toxaemia  pronounced.  As  a  rule  the  constitutional  symptoms  are  directly 
proportional  to  the  local  involvement. 

A  marked  leucocytosis  is  usually  present  in  diphtheria  even  of  mild  type 
and  albuminuria  occurs  in  nearly  all  severe  infections. 

Complications  and  Sequelae.  The  slight  albuminuria  which  is  so 
commonly  seen  is  not  to  be  attributed  to  nephritis  but  the  appearance 
of  blood  and  epithelial  casts  and  the  occurrence  of  diminution  of  the 
urine  indicate  that  serious  kidney  involvement  is  present.  (Edema  is 
less  frequent  than  in  scarlatina  and,  while  the  nephritis  of  diphtheria 
usually  terminates  in  recovery,  it  may  cause  death.  Bronchitis  and  broncho- 
pneumonia are  important  and  serious  complications.  Pericarditis  and 
endocarditis  are  rare.  The  heart  is  often  irregular  and  an  apical  systolic 
murmur  is  present  in  a  large  majority  of  instances.  Heart  weakness,  evidenced 
by  rapid  and  galloping  rhythm  and  by  sudden  diminution  in  the  pulse  rate, 
is  a  serious  manifestation.     The  cardiac  symptoms  usually  appear  from  the 


DIPHTHERIA.  QI 

loth  to  the  2oth  day  of  the  disease  but  fatal  acute  dilatation  may  occur  in 
convalescence,  even  as  late  as  the  seventh  v^^eek. 

Minor  complications,  such  as  nasal  or  pharj-ngeal  haemorrhage,  various 
skin  eruptions  and  jaundice,  are  not  uncommon. 

Paralysis  is  a  most  important  sequel  and  is  a  result  of  neuritis  due  to  the 
toxins  of  the  disease.  It  may  appear  as  early  as  the  seventh  day  or  not  until 
convalescence  and  as  frequently  follows  mild  as  severe  cases.  It  occurs  in 
ID  percent,  to  20  percent,  of  patients  and  is  more  frequent  in  adults  than  in 
children.  The  palate  is  most  often  affected  and  involvement  of  this  struc- 
ture is  evidenced  by  nasal  voice  and  the  regurgitation  of  food  through  the 
nostrils.  The  pharynx  is  anaesthetic.  Involvement  of  the  muscles  of  deglu- 
tition is  also  frequent  and  various  ocular  palsies  are  not  rare;  neuritis  may 
occur  in  the  extremities  resulting  in  permanent  disability.  Recovery  usually 
takes  place  from  these  paralyses  within  a  few  weeks.  Multiple  neuritis  may 
be  observed  which  may  rarely  involve  the  innervation  of  the  heart  and  the 
respiratory  muscles,  in  which  event  the  patient's  condition  is  dangerous. 

The  diagnosis  can  be  assured  only  by  bacteriological  examination  of  the 
false  membrane;  fortunately  this  is  not  a  difficult  procedure,  and  where  there 
is  no  health  department  affording  facilities  for  laboratory  diagnosis,  it  may 
be  carried  out  by  the  practitioner.  For  a  description  of  the  technique  the 
reader  is  referred  to  any  good  work  upon  clinical  diagnosis. 

The  prognosis  since  the  introduction  of  the  antitoxin  treatment  has  been 
rendered  vastly  more  favorable  than  previous  to  this  event.  By  this  remark- 
able therapeutic  advance  the  mortality  from  diphtheria  has  been  reduced 
from  30  percent,  to  50  percent,  to  from  10  percent,  to  15  percent.  The  prog- 
nosis is  excellent  in  the  usual  infections.  Complications  and  laryngeal  in- 
volvement render  it  less  good.  Sudden  heart  failure,  paralyses  and  uraemia 
may  result  fatally. 

Prevention.  Prophylaxis  in  diphtheria  has  been  further  developed  and 
is  more  successful  than  in  any  other  infectious  disease  save  smallpox.  The 
following  condensation  of  the  rules  concerning  the  disease  laid  down  by  the 
New  York  Health  Department  covers  the  subject  of  prevention  very 
thoroughly. 

If  possible  one  person  should  take  entire  charge  of  the  patient  and  no  one 
else  except  the  physician  should  be  allowed  in  the  sick-room.  The  nurse 
should  hold  no  communication  with  the  rest  of  the  family,  who  should  not 
receive  or  make  visits  during  the  illness.  Discharges  from  nose  and  mouth 
must  be  received  on  cloths  which  should  be  immediately  immersed  in  phenol 
solution  (six  ounces  ( 180.0)  of  pure  phenol  added  to  one  gallon  (4  liters) 
of  hot  water  and  diluted  with  an  equal  quantity  of  water).  All  handkerchiefs, 
towels,  bed  linen,  clothing,  etc.,  that  have  come  in  contact  with  the  patient, 
after  use  must  be  at  once  immersed,  without  removal  from  the  room,  in  the 


92  THE    INFECTIOUS    DISEASES. 

above  solution.  These  should  be  soaked  for  two  or  three  hours  and  then 
boiled  in  water  for  one  hour. 

The  greatest  care  should  be  taken  in  making  applications  to  the  throat 
and  nose  lest  the  discharges  be  coughed  into  the  face  or  upon  the  clothing  of 
the  attendant.  A  pane  of  glass  held  between  the  patient  and  the  physician 
will  effectually  prevent  this  accident. 

The  hands  of  the  attendant  should  always  be  disinfected  by  washing  in  the 
phenol  solution  and  in  soapsuds  after  making  applications  and  before  eating. 

Surfaces  of  any  kind  soiled  by  discharges  should  be  immediately  flooded 
with  phenol  solution. 

All  utensils  used  by  the  patient  must  be  kept  for  his  use  alone  and  must 
not  be  removed  from  the  room,  but  must  be  washed  in  the  phenol  solution 
and  in  hot  soapsuds.  After  use  the  soapsuds  should  be  thrown  in  the  water- 
closet  and  the  vessel  which  contained  It  washed  in  the  phenol  solution. 

The  sick-room  should  be  thoroughly  aired  two  or  three  times  a  day  and 
should  be  swept  frequently,  after  scattering  wet  sawdust  or  tea  leaves  on  the 
floor  to  prevent  the  dust  from  rising.  After  sweeping,  the  room  should  be 
dusted  with  damp  cloths.  The  sweepings  should  be  burned  and  the  cloths 
soaked  in  the  phenol  solution. 

When  the  disease  is  recognized  shortly  after  the  beginning  of  the  illness  all 
hangings  and  unnecessary  furniture  should  be  removed  from  the  sick-room. 

After  recovery,  the  patient's  body  and  hair  should  be  washed  with  hot  soap- 
suds, he  should  be  dressed  in  clean  clothes,  which  have  not  been  in  the  room 
during  the  iUness,  and  taken  from  the  apartment. 

The  quarantine  should  last  as  long  as  the  diphtheria  bacilli  are  found  upon 
the  mucous  membranes;  they  may  persist  for  six  or  eight  weeks. 

The  nurse  and  physician  should  wear,  while  in  the  sick-room,  a  gown  which 
covers  the  clothing  completely.  This  should  be  kept  just  outside  the  apart- 
ment and  should  be  sterilized  directly  after  use.  ■  If  the  patient,  while  the 
throat  is  being  examined,  should  cough  in  the  examiner's  face,  the  latter 
should  wash  the  face  and  hair  in  soap  and  water  followed  by  i  to  i,ooo 
mercury  bichloride  solution.  The  hands  must  always  be  sterilized  upon 
leaving  the  sick-room.  The  nurse  should  spray  or  gargle  her  throat  several 
times  a  day  with  a  mild  antiseptic,  such  as  Dobell's  solution. 

It  is  strongly  advisable  that  the  nurse  and  members  of  the  family,  if  they 
have  been  exposed,  should  receive  an  immunizing  dose  (loo  units  for  a  child 
under  the  age  of  one  month  to  800  units  for  an  adult)  of  antitoxin,  and  at 
the  first  sign  of  sore  throat  a  full  dose  must  be  given.  The  effect  of  an 
immunizing  dose  lasts  about  four  weeks  and  at  the  close  of  this  period  a 
second  dose  should  be  given  if  there  is  continued  exposure. 

After  removal  of  the  patient  the  room  and  its  contents  should  be  properly 
disinfected  and  aired. 


DIPHTHERIA.  93 

Treatment.  The  patient  should  be  immediately  isolated,  especially  if 
the  disease  is  complicated  by  pneumonia,  in  an  apartment  which  should  be 
kept  cool  (65°  F. — 18.5°  C.)  and  freely  ventilated.  If  practicable,  in  hospitals 
it  is  always  better  to  assign  each  patient  a  separate  room  than  to  collect  the 
sufferers  in  a  ward.  From  the  onset  of  the  disease  until  all  possible  danger 
of  heart  failure  is  past  the  patient  should  be  kept  in  bed.  At  the  beginning 
of  the  treatment  the  bowels  should  be  freely  opened  by  means  of  fractional 
doses  of  calomel  to  be  followed  by  a  saline  and  regular  daily  movements 
should  be  obtained  throughout  the  course  of  the  disease. 

The  treatment  of  diphtheria  by  antitoxin  is  attended  with  such  good  results 
and  has  so  few  disadvantages  and  dangers  that  it  should  always  be  employed. 
All  patients  in  whom  the  symptoms  and  clinical  appearances  resemble  those 
of  diphtheria  should  receive  the  treatment  without  waiting  24  hours  or  more 
to  learn  the  result  of  a  bacteriological  examination.  By  enforcing  this  rule 
we  may  give  antitoxin  to  many  patients  to  whom  it  is  unnecessary  but  it  is 
better  to  do  this  than  to  allow  one  individual  who  is  suffering  from  true 
diphtheria  to  wait  even  a  few  hours. 

The  antitoxin  of  any  reputable  producer  may  be  used  and  the  technique 
of  its  administration  is  simple.  An  ordinary  hypodermatic  syringe  or  the  in- 
jection outfit  provided  by  the  maker  of  the  serum  may  be  used.  The  needle 
should  be  sterilized  and  the  skin  of  the  selected  site,  which  is  usually  the 
thigh,  buttock  or  side  of  the  chest,  bathed  with  soap  and  hot  water,  washed 
with  alcohol  and  i  to  5,000  mercury  bichloride  solution.  The  serum  should 
then  be  slowly  injected,  the  needle  withdrawn  and  the  puncture  covered 
with  a  bit  of  sterile  gauze  held  in  place  by  adhesive  plaster. 

The  quantity  of  the  antitoxin  administered  depends  upon  the  severity 
of  the  infection  and  the  age  of  the  patient.  After  the  first  injection  the  dosage 
should  be  regulated  by  the  effect  produced  and  is  limited  by  this  consideration 
alone.  The  most  concentrated  serum  obtainable  should  be  used  so  that  the 
bulk  of  the  dose  should  be  as  small  as  possible.  In  mild  cases  one  dose  of 
2,000  to  3,000  units  is  often  sufiicient,  a  unit  being  the  amount  required  to 
neutralize  the  amount  of  diphtheria  toxin  necessary  to  kill  100  small  guinea 
pigs;  5,000  units  is  a  proper  initial  dose  for  a  child  of  two  years  with  a  severe 
infection.  All  cases  with  laryngeal  involvement  should  receive  a  dose  at  least 
as  large.  Late  in  the  disease,  when  the  condition  is  profoundly  toxic,  10,000 
units  may  be  given  and  repeated  until  the  condition  is  ameliorated.  Too  great 
insistence  cannot  be  laid  upon  the  importance  of  giving  large  doses  in  severe 
infections  for  it  is  possible  by  this  means  to  save  seemingly  hopeless  cases. 
The  treatment  is  harmless  and  amounts  of  over  100,000  units  have  been 
given.  The  favorable  action  of  the  antitoxin  is  evidenced  as  a  rule  within  24 
hours  and  often  within  less  time.  The  membrane  ceases  to  spread  and  be- 
comes softer  and  more  easily  detachable.     The  surrounding  and  underlying 


94 


THE    INFECTIOUS    DISEASES. 


mucous  membrane  rapidly  assumes  a  normal  appearance.  In  nasal  and 
laryngeal  diphtheria  the  amelioration  of  the  local  inflammation  is  quite  as 
evident.  The  glandular  swellings  diminish  and  at  the  same  time  the  consti- 
tutional symptoms  clear,  the  temperature  falling,  the  heart  action  becoming 
stronger  and  the  prostration  less  marked. 

It  is  important  to  keep  in  mind  the  fact  that  the  antitoxin,  in  order  to  exert 
its  best  effect,  must  be  given  early.  One  should  not  wait  for  an  assured  bac- 
teriological diagnosis  but  the  treatment  should  be  instituted  as  soon  as  the 
patient  is  seen.  The  serum  is  impotent  to  check  such  complications  as 
septic  infection,  nephritis  and  broncho-pneumonia. 

Unfavorable  Effects  of  Antitoxin.  Authentic  instances  of  sudden  death 
have  never  been  reported  and  the  consensus  of  opinion  is  that  the  treatment 
is  harmless.  Various  skin  eruptions,  especially  urticaria,  may  follow  injection 
and  instances  of  arthritis  and  abscess  have  been  reported.  The  latter  are  not 
often  seen  and,  considering  the  advantages  of  the  antitoxin  treatment,  are 
wholly  negligible. 

Local  treatment  has  become  less  important  since  the  introduction  of  anti- 
toxin but  still  holds  a  considerable  place  in  the  management  of  diphtheria. 
The  object  sought  is  cleanliness  rather  than  the  destruction  of  the  bacilli. 
In  many  instances  it  is  difficult  of  accomplishment  owing  to  the  objections  of 
the  patient.  If  the  child  is  prone  to  struggle  it  is  better  not  to  employ  force, 
and  in  such  patients  the  local  treatment  may  be  omitted.  The  most  approved 
method  is  to  irrigate  the  nose  and  pharj^nx  with  mild  solutions,  such  as  normal 
sodium  chloride  or  weak  boric  acid,  as  hot  as  the  patient  will  bear,  by  means  of 
a  fountain  syringe  or  rubber  hand  syringe  to  which  a  soft  rubber  catheter  is 
attached.  The  child  should  lie  on  his  side  with  the  head  slightly  lower  than 
the  rest  of  the  body  so  that  the  irrigation  can  readily  flow  from  the  mouth 
into  a  convenient  receptacle.  In  severe  infections  such  irrigations  should  be 
given  every  two  or  three  hours. 

Nasal  syringing  is  necessary  in  patients  with  nasal  discharge  and,  in  those 
with  pronounced  symptoms  and  evident  marked  nasal  involvement,  is  abso- 
lutely necessary.  If  there  is  epistaxis  the  irrigations  should  be  temporarily 
omitted  and  sprays  of  suprarenal  extract,  lo  percent,  calcium  cliloride  solution 
or  of  weak  alum  solution  may  be  employed. 

In  mild  infections,  when  practicable,  mild  antiseptic  alkaline  sprays  should 
be  used  both  upon  the  nose  and  pharynx.  Dobell's  solution  or  diluted  liquor 
antisepticus  (U.S. P.)  are  applicable  for  ihis  purpose. 

Direct  applications  to  the  site  of  the  inflammation  arc  used  less  now  than  form- 
erly but  many  physicians  approve  them.  The  patient  should  be  warmly  wrapped 
and  held  by  the  nurse,  the  mouth  being  held  open  by  a  cork  between  the 
teeth  or  by  a  mouth  gag,  while  the  application  is  made  by  means  of  a  cotton 
swab  or  a  brush.     Various  solutions  may  be  employed,  that  originated  by 


DIPHTHERIA.  95 

Loffler  being  one  of  the  most  efficient.  It  consists  of  lo  parts  of  menthol, 
26  parts  of  toluol,  liquor  ferri  sesquichlorati  4  parts  and  absolute  alcohol  60 
parts.  Other  solutions  which  may  be  used  are  10  percent,  lactic  acid;  one 
part  of  mercury  bichloride  to  1,000  parts  normal  sodium  chloride;  mercury 
bichloride  i  part,  tartaric  acid  5  parts,  water  1,000  parts;  phenol  3  parts, 
rectified  oil  of  turpentine  40  parts;  absolute  alcohol  60  parts;  hydrogen  dioxide 
solution,  etc.  Such  applications  may  be  made  to  the  inflamed  surface  every 
three  to  six  hours.  ' 

Insuffiations  of  various  powders  such  as  bismuth  subgallate,  thymol  iodide 
(aristol),  nosophen,  i  part  iodoform  to  5  parts  sodium  bicarbonate  may  be 
given,  but  the  disease  can  be  managed  very  satisfactorily  without  this  form 
of  treatment. 

External  applications  to  the  throat  in  the  form  of  poultices  are  not  indi- 
cated. Ice  bags,  however,  may  lessen  both  the  pharyngeal  inflammation  and 
the  tendency  to  enlargement  of  the  cervical  and  submaxillary  glands.  Suck- 
ing bits  of  ice  often  makes  the  patient  more  comfortable  and  may  influence 
the  pharyngeal  inflammation.  In  glandular  enlargement  and  tendency  to 
cervical  suppuration  inunctions  of  unguentum  Crede  and  injections  of  anti- 
streptococcus  serum  are  valuable  since  suppuration  in  diphtheria  is  considered 
to  be  due  to  mixed  infection  with  pyogenic  micro-organisms. 

In  the  early  stages,  and  especially  in  laryngeal  diphtheria,  steam  inhalations 
by  means  of  a  croup  kettle,  the  spout  of  which  is  introduced  under  a  tent  of 
blankets  constructed  over  the  child's  crib,  are  indicated.  The  steam  may  be 
that  from  plain  water,  lime  water,  2^  percent,  lactic  acid  solution,  3  percent, 
phenol  solution,  one  drachm  of  eucalyptol  or  benzoinol  to  a  pint  of  water,  etc. 

In  laryngeal  diphtheria  with  obstruction  and  pronounced  dyspnoea  emetics 
should  be  given.  Here  syrup  of  ipecac  may  be  administered  in  teaspoonful 
doses  to  a  child  of  three  years  every  15  to  30  minutes  until  emesis  is  induced, 
or  a  teaspoonful  of  the  following  formula  may  be  given  in  the  same  way. 
I^  pulveris  ipecacuanhse,  gr.  xxii  ss  (1.5);  antimonii  et  potassii  tartratis,  gr.  i 
(0.065);  syrupi  scillce,  §i  (30.0);  aquie  destillatae,  §iv  (120.0). 

Laryngeal  obstruction  which  does  not  yield  quickly  to  this  form  of  treat- 
ment necessitates  immediate  intubation  or  tracheotomy. 

The  internal  administration  of  drugs  with  the  hope  of  influencing  the 
course  of  the  disease  is  considered  by  many  authorities  quite  useless  while 
among  the  more  conservative  the  old  idea  still  prevails  and  drug  medication 
is  prescribed  as  before  the  introduction  of  antitoxin.  Mercury  bichloride  is 
given  to  adults  in  doses  of  ^^  to  -^^  o^  ^  grain  (0.0012  to  0.005)  every  two 
hours  with  potassium  chlorate  and  tincture  of  iron  chloride,  in  the  hope  of 
causing  the  membrane  to  loosen.  For  children  the  dosage  should  be  some- 
what lower.  Toxic  effects  are  not  likely  to  occur  since  digestive  disturb- 
ances usually  appear  before  any  harm  is  done.     Calomel  is  also  given  with 


96  THE   INFECTIOUS    DISEASES. 

the  same  object  in  view,  in  fractional  doses,  I  to  ^  of  a  grain  (o.oii  to 
0.008)  every  hour,  until  free  diarrhoea  is  induced. 

The  saturated  solution  of  potassium  chlorate  was  for  long  the  classical 
mouth  wash  in  diphtheria  and  is  still  prescribed  by  some  but  it  is  in  no  way 
preferable  to  the  solutions  previously  suggested.  Gargling  with  potassium 
chlorate  solution  is  inferior  to  irrigating  and  spraying,  for  it  is  almost  impossible 
to  bring  the  gargle  into  contact  with  the  seat  of  the  inflammation  if  it  is  behind 
the  pillars  of  the  fauces.  Iron  and  quinine  may  be  given  through  the  course 
of  the  disease  in  the  hope  of  supporting  the  patient's  strength. 

Stimulation  becomes  necessary  as  soon  as  the  toxaemia  is  evidenced  by  the 
general  condition  and  by  tendency  to  heart  weakness.  In  mild  infections 
stimulants  may  be  unnecessary  but  most  patients  will  require  alcohol  sooner 
or  later.  The  need  of  its  exhibition  is  shown  by  marked  constitutional  symp- 
toms and  feebleness  of  the  pulse.  The  dosage  should  be  regulated  by  the 
patient's  condition  and  either  brandy  or  whiskey,  diluted  with  water,  may  be 
given.  Half  a  drachm  (2.0)  every  three  hours  is  a  proper  amount  for  a  child 
of  five  years.  This  quantity  may  be  increased  as  necessary.  Strychnine  is 
valuable  and  digitalis  may  be  given  in  small  doses  if  there  is  low  arterial  tension 
combined  with  cardiac  weakness.  Sudden  heart  weakness  necessitates  the 
administration  of  stimulants  hypodermatically  and  here  we  may  give  camphor 
dissolved  in  aether  or  in  sterile  oil.  Hypodermatic  injections  of  morphine 
in  appropriate  doses  are  said  to  be  our  best  means  of  combating  the  cardiac 
paralysis  which  is  so  much  to  be  dreaded  in  diphtheria. 

When  there  is  evidence  of  obstruction  to  respiration,  due  to  excessive  forma- 
tion of  membrane  in  the  larynx,  intubation  or  tracheotomy  becomes  neces- 
sary. The  former  procedure  possesses  the  following  advantages:  It  is  safe, 
rapid  and  without  danger,  is  free  from  shock,  needs  no  anaesthesia,  no  wound 
is  made,  the  patients  make  no  objection  and  the  air  taken  into  the  lungs  is 
warmed  and  filtered  by  its  passage  through  the  upper  air  passages.  Intuba- 
tion relieves  the  mechanical  obstruction  and  the  indication  for  its  performance 
is  dyspnoea  which  necessitates  relief.  Cyanosis  is  not  a  safe  guide.  When 
there  is  evident  effort  in  respiration  as  shown  by  the  action  of  the  abdominal, 
thoracic  and  cervical  muscles,  weak  heart  action  and  coldness  of  the  extremi- 
ties, constitutional  depression  and  e^'idence  of  marked  toxaemia,  intubation 
should  be  performed  at  once.  It  is  far  better  to  intubate  too  early  than  to 
wait  until  too  late.  In  a  few  instances  the  laryngeal  membrane  may  be 
pushed  into  the  trachea  by  the  introduction  of  the  tube  but  if  the  latter  is 
withdrawn  immediately  the  former  will  be  coughed  up;  if  this  does  not  take 
place  tracheotomy  must  be  done  at  once.  The  operation  of  intubation  is  not 
difficult  and  a  moderate  amount  of  practice  upon  the  cadaver  or  upon  dogs 
will  render  the  physician  proficient.  O'Dwyer's  original  tube  is  best,  but  while 
he  was  accustomed  to  intubate  with  the  patient  in  the  erect,  position,  the 


MUMPS.  97 

horizontal  is  preferable,  especially  if  there  is  tendency  to  marked  prostration 
or  cardiac  weakness. 

Diphtheritic  paralysis  should  be  treated  by  rest  in  bed  and,  if  persistent, 
by  means  of  strychnine,  electricity,  massage  and  hydrotherapeutic  measures. 

During  convalescence  the  patient  should  be  kept  in  bed  until  aU  danger  of 
heart  failure  is  past,  this  complication  being  prone  to  occur  for  some  time 
after  the  acuity  of  the  disease  is  over. 

The  diet  should  be  fluid  and  it  is  very  important  that  the  patient  should 
get  sufficient  nourishment.  If  niirsing,  the  child  should  not  be  allowed  the 
breast  but  should  be  fed  upon  milk  withdrawn  by  means  of  the  breast  pump. 
For  older  children  dilute  cow's  milk,  if  necessary  peptonized,  should  be  the 
chief  food.  If  is  often  necessary,  in  order  that  the  child  shall  receive  plenty 
of  food,  especially  in  the  later  stages  of  the  disease,  when  the  appetite  is  insuffi- 
cient and  there  is  pain  and  difficulty  in  swallowing,  to  feed  the  patient  by  means 
of  the  stomach  or  nasal  tube.  The  latter  is  especially  to  be  employed  in 
children  who  object  to  the  former  and  in  those  who  have  been  subjected  to 
intubation  or  tracheotomy.  The  food  should  be  predigested  in  so  far  as  is 
possible.  The  operation  is  performed  with  the  patient  upon  his  back  and 
the  stomach  should  be  washed  before  each  feeding.  Medicines  may  also 
be  administered  by  means  of  the  tube.  Each  feeding  should  be  of  considerable 
size  for  of  necessity  the  operation  cannot  be  performed  at  frequent  intervals. 

The  quarantine  should  be  continued  until  cultures  from  the  throat  show 
the  presence  of  no  diphtheria  bacilli.  The  treatment  of  diphlheroid  infections 
(pseudo-diphtheria)  is  the  same  as  for  true  diphtheria,  save  that  antitoxin 
is  not  indicated.     Antistreptococcus  serum  may  be  given  in  its  stead. 

MUMPS. 

Synonym.     Epidemic  Parotitis. 

Definition.  An  acute  infectious  disease  characterized  by  inflammation 
of  one  or  both  parotid  glands,  sometimes  extending  to  the  submaxillary 
glands  and  rarely  to  the  testicles,  ovaries  and  mammary  glands. 

.etiology.  This  disease  is  most  common  in  childhood  and  youth  and 
is  most  likely  to  occur  in  the  spring  and  fall.  The  infection  is  uncommon 
in  young  infants  and  in  adults  and  attacks  boys  more  frequently  than  girls. 
Sporadic  instances  of  mumps  are  generally  present  in  cities  and  epidemics 
occur  at  intervals.  The  disease  is  communicable  from  person  to  person  but 
the  specific  cause  of  the  contagion  is  not  known;  one  attack  usually  confers 
immunity. 

Pathology.  The  morbid  anatomy  of  this  disease  consists  of  a  congestion 
and  oedema  of  the  salivary  glands  with  swelling  of  the  walls  of  their  ducts 
resulting  in  obstruction  of  their  lumen. 

Symptoms.  The  incubation  period  is  from  two  to  three  weeks.  Pro- 
7 


98  THE    INFECTIOUS    DISEASES. 

dromal  symptoms  are  rare  and  in  mild  infections  the  initial  symptoms  are 
referable  to  the  affected  gland.  In  the  sevv^rer  types  there  may  be  such  symp- 
toms at  the  invasion  of  the  infection  as  headache,  general  bodily  pains,  loss  of 
appetite,  vomiting  and  a  rise  of  temperature,  in  mild  instances  rarely  above 
101°  F.  (38.3°  C),  but  in  the  severe  forms  the  fever  may  reach  103°  to  104°  F. 
(39.5°  to  40°  C).  The  first  local  symptom  is  usually  pain  below  and  in  front 
of  the  ear,  pain  in  swallowing  is  often  present  and  swelling  soon  becomes 
apparent  in  both  parotid  glands  simultaneously  or  more  often  in, one,  the  other 
becoming  involved  two  or  three  days  later  or  not  at  all.  The  swelling  is  in 
front  of  and  below  the  ear  and  may  affect  the  entire  neck  in  this  vicinity. 
The  lobe  of  the  ear  is  everted  and  occupies  the  central  part  of  the  tumor. 
The  swelling  reaches  its  greatest  size  in  from  two  to  three  days  and  at  this 
time  the  pain  may  be  severe  and  the  difficulty  in  swallowing  marked,  opening 
the  mouth  and  mastication  may  be  well-nigh  impossible,  the  secretion  of  saliva 
is  diminished,  and  there  may  be  earache. 

The  disease  is  usually  mild  but  in  rare  instances  disturbing  and  even  danger- 
ous symptoms,  such  as  delirium  resvilting  from  pressure  upon  the  veins  of  the 
neck  and  consequent  cerebral  congestion,  may  occur.  Suppuration  of  the 
glands  is  rare. 

The  fever  lasts  four  or  five  days  but  the  swelling  may  last  a  week  or  more. 
The  opposite  side  may  become  involved  after  the  original  site  of  the  disease 
has  returned  to  normal. 

Complications  are  rare  in  young  children  but  in  youths  orchitis  may  occur 
after  the  inflammation  of  the  parotids  has  subsided.  The  body  of  the  testic  e 
is  affected  rather  than  the  epididymis  and  both  organs  may  be  involved. 
The  onset  of  this  complication  is  marked  by  a  rise  in  temperature,  the  testicle 
is  swollen,  painful  and  tender;  the  acuity  of  the  inflammation  lasts  several 
days  but  the  swelling  persists  for  a  few  weeks  and  rarely  atrophy  may  result. 
Hydrocele  of  the  tunica,  oedema  of  the  scrotum  and  a  muco-purulent  urethral 
discharge  may  accompany  the  orchitis. 

Ovaritis,  and  inflammation  of  the  vulva  and  of  the  mammary  glands  may 
occur  in  girls. 

Still  rarer  complications  are  nephritis,  otitis  media  and  deafness,  pneu- 
monia, pericarditis,  endocarditis,  meningitis  and  facial  paralysis.  Enlarge- 
ment of  the  thyroid  gland  and  symptoms  suggestive  of  pancreatic  inflamma- 
tion have  been  observed.  Following  the  disease,  permanent  hypertrophy  of 
the  parotid  may  be  noted. 

The  diagnosis  is  usually  easy.  Mumps  is  most  likely  to  be  mistaken  for 
acute  cervical  lymphangitis  but  may  be  differentiated  by  the  characteristic 
shape  of  the  parotid  tumor  and  by  the  elevation  of  the  lobe  of  the  ear. 

The  prognosis  is  very  favorable,  especially  in  the  absence  of  complications. 

Treatment.     Isolation  is  necessary  in  institutions  and  in  families  where 


WHOOPING    COUGH,  99 

there  are  other  children,  and  the  quarantine  should  be  continued  for  at  least 
three  weeks.  At  the  onset  of  the  disease  the  patient's  bowels  should  be 
opened  and  if  there  is  fever  he  should  be  put  to  bed  and  kept  there  until  all 
constitutional  symptoms  have  disappeared.  Avoidance  of  exposure  will 
diminish  the  Uability  to  comphcations.  The  pain  in  the  swollen  gland  may 
be  diminished  by  compresses  of  gauze  impregnated  with  a  mixture  of 
fluid  extract  of  belladonna,  ni^  xx  (1.33)  and  an  ounce  (30.0)  of  glycerin, 
with  a  5  percent,  ointment  of  ichthyol  or  a  2  percent,  morphine  ointment. 
The  compress  should  be  covered  with  rubber  tissue  or  oiled-silk.  Cold  com- 
presses may  be  grateful  to  the  patient  but  the  application  of  heat  is  usually 
preferred.  Should  the  fever  give  rise  to  anxiety  an  ice  coil  may  be  applied 
to  the  precordium  but  this  will  seldom  be  found  necessary.  Other  symptoms 
should  be  treated  as  they  arise. 

If  enlargement  and  hardness  of  the  parotid  persists  after  the  acuity  of  the 
infection  has  subsided,  inunctions  of  6  percent,  iodine-vasogen  or  of  a  potas- 
sium iodide  ointment  are  suggested. 

The  orchitis  necessitates  rest  in  bed,  support  of  the  testicles  by  means  of  a 
bridge  across  the  thighs  made  of  a  strip  of  adhesive  plaster  and  the  application 
of  a   10  percent,  ointment  of  ichthyol. 

The  dryness  of  the  mouth  should  be  relieved  by  washes  of  dilute  liquor 
antisepticus. 

The  diet  should  be  fluid  while  the  temperature  is  elevated  and  even  if  this 
symptom  is  absent  it  may  be  impossible  for  the  patient  to  take  solids  because 
of  the  pain  upon  mastication  and  deglutition. 

WHOOPING  COUGH. 

Synonym.     Pertussis. 

Definition.  A  specific  infectious  disease  characterized  by  catarrhal  in- 
flammation of  the  air  passages  and  by  paroxysms  of  coughing  accompanied 
by  long   inspirations  producing  the   typical   "whoop." 

.Etiology.  This  disease  is  endemic  in  cities  and  from  time  to  time  epi- 
demics appear,  especially  in  the  winter  and  spring  and  often  associated  with 
epidemics  of  measles  or  scarlatina.  Children  are  most  frequently  attacked 
and  the  most  susceptible  period  is  between  the  first  and  second  dentitions. 
Nursing  infants  and  adults  may,  however,  contract  the  infection  and  in  old 
persons  it  is  likely  to  be  serious.  Delicate  children  and  those  prone  to  catar- 
rhal affections  are  particularly  liable  to  infection.  Whooping  cough  is  most 
contagious  during  the  catarrhal  stage  and  is  generally  spread  by  direct  con- 
tact but  schools,  dweUings,  etc.,  may  be  infected. 

Various  observers  have  described  micro-organisms  which  they  consider 
responsible  for  the  occurrence  of  the  disease  but  their  claims  have  not  as 
yet  been  substantiated. 


lOO  THE    INFECTIOUS    DISEASES. 

Immunity  is  usually  conferred  by  one  attack,  and,  while  certain  individuals 
seem  unable  to  contract  the  affection,  it  must  not  be  forgotten  that  the  dis- 
ease may  occur  in  a  mild  form  which  may  be  overlooked. 

Pathology.  There  is  no  constant  morbid  change  associated  with  whoop- 
ing cough.  Complications  are  usually  responsible  for  fatalities  and  here  we 
find  the  causative  lesions  such  as  broncho-pneumonia,  bronchitis,  collapse 
of  the  lung,  vesicular  and  interstitial  emphysema  and  enlargement  of  the 
tracheal  and  bronchial  lymph  nodes.  After  death  during  a  paroxysm  the 
brain  is  found  in  a  state  of  congestion  and  punctate  or  larger  haemorrhages 
may  be  present. 

Symptoms.  After  a  period  of  incubation  of  from  7  to  lo  days  the  first 
or  catarrhal  stage  sets  in.  This  is  marked  by  slight  rise  in  temperature,  run- 
ning at  the  nose,  conjunctival  injection,  sore  throat  and  cough,  usually  dry, 
and  at  times  paroxysmal.  The  characteristic  whoop  may  be  present  from 
the  onset  but  more  commonly  after  a  week  or  10  days  of  atypical  cough 
the  tendency  to  the  whoop  becomes  gradually  more  marked,  the  spasms 
are  more  and  more  frequent  and  the  paroxysmal  stage  begins.  A  typical 
fit  of  coughing  begins  with  15  to  20  short  expiratory  coughs  between 
which  there  is  no  effort  at  inspiration.  The  face  is  flushed  and  perhaps 
cyanotic,  the  eyes  are  prominent,  there  is  lacrymation  and  nasal  discharge. 
At  the  termination  of  the  paroxysm  there  is  a  deep  inspiration  accompanied 
by  a  whoop.  Such  a  fit  of  coughing  may  be  immediately  succeeded  by 
another,  be  terminated  by  the  expectoration  of  more  or  less  mucus  or  fol- 
lowed by  emesis.  The  paroxysms  vary  in  number  from  four  or  five  daily, 
to  ten  times  this  number.  The  patient  recognizes  the  imminence  of  the 
coughing  fits  and  endeavors  to  prevent  them.  Frequent  vomiting  may  render 
the  child  emaciated  as  a  result  of  its  inability  to  retain  sufficient  nourishment. 
An  ulcer  due  to  friction  against  the  lower  incisors,  may  form  at  the  fraenum 
of  the  tongue;  rupture  of  a  nasal  or  conjunctival  vessel  and  involuntary  urina- 
tion may  occur  during  a  paroxysm. 

Physical  examination  of  the  thorax  during  the  spasm  reveals  diminished 
pulmonary  resonance  during  the  expiratory  coughs  and  normal  resonance 
during  the  inspiration.  During  the  whoop  there  may  be  absence  of  the 
normal  vesicular  murmur  on  account  of  the  slowness  with  which  air  enters 
the  lungs.     Mucous  rS.les  may  be  present. 

The  attacks  of  coughing  may  be  induced  by  emotion,  irritating  inhalations 
and  even  by  deglutition.  The  paroxysmal  stage  of  the  disease  lasts  from  one 
month  to  six  weeks,  increasing  in  intensity  for  the  first  half  of  this  period,  then 
remaining  stationary  for  about  a  week  and  then  gradually  subsiding.  The 
paroxysms  are  very  likely  to  recur  if  the  patient  catches  cold  or  if  his 
digestion  becomes  disordered.  This  reappearance  of  the  whoop  is  not  to  be 
considered  a  true  relapse. 


WHOOPING    COUGH.  .  lOI 

The  stage  of  convalescence  lasts  from  three  to  four  weeks  but  may  be  much 
longer  than  this  period. 

Complications  are  frequent  and  sometimes  serious.  The  congestion 
caused  by  the  paroxysm  may  cause  bleeding  from  the  nose,  conjunctiva  or 
even  the  ears,  as  well  as  petechial  ha?morrhages  into  the  skin,  haemoptysis 
and  intestinal  haemorrhage.  Intracranial  extravasations  of  blood  may  occur, 
causing  death,  various  paralyses  or  convulsions.  These  haemorrhages  are 
seldom  large  and  their  manifestations  are  rarely  permanent.  Disturbances 
of  the  special  senses  are  sometimes  noted. 

Pulmonary  complications  are  usually  responsible  when  death  takes  place. 
Both  broncho-  and  lobar  pneumonia  may  be  observed.  Inflammation  of 
the  larger  bronchi  is  the  rule  and  is  not  especially  to  be  feared;  involvement 
of  the  small  tubes  is  as  serious  as  broncho-pneumonia.  Transient  vesicular 
emphysema  is  not  uncommon,  being  caused  by  the  severity  of  the  paroxysm; 
interstitial  and  even  subcutaneous  emphysema  have  been  observed.  En- 
largement of  the  bronchial  glands  is  common. 

Infants  suffering  from  pertussis  in  summer  are  very  frequently  affected 
with  diarrhoea.  Malnutrition  may  result  from  the  frequent  emesis  caused 
by  the  paroxysms. 

Albuminuria  and  glycosuria  may  occur  but  these  conditions  are  usually 
only  temporary.  Overstrain  of  the  heart  may  result  in  permanent  valvular 
endocarditis  and,  as  sequelae,  hernia,  prolapsus  ani  and  a  predisposition  to 
tuberculosis  may  be  mentioned. 

The  diagnosis  in  typical  instances  may  be  easily  made;  others  may  occur, 
in  which  there  is  no  whoop;  here  the  problem  is  much  more  difficult,  but 
a  cough,  occurring  chiefly  at  night,  which  increases  in  severity  for  two  or 
three  weeks,  is  unaccompanied  by  constitutional  symptoms  and  physical 
signs  and  which  may  manifest  itself  in  paroxysms  followed  by  vomiting,  is 
probably  pertussis.  In  the  presence  of  epidemics  the  diagnosis  is  greatly 
simplified.  An  increase  in  the  number  of  leucocytes,  particularly  of  the 
lymphocytes,  is  an  important  feature  of  this  disease. 

The  prognosis  is  distinctly  bad  in  children  under  four  years  of  age  and  in 
those  previously  delicate,  broncho-pneumonia  being  responsible  for  many 
of  the  deaths. 

Treatment.  The  patient  should  be  kept  from  association  with  other 
children;  confinement  to  a  single  room  is  unnecessary,  consequently  all  indi- 
viduals to  whom  the  infection  is  prejudicial  should  be  sent  away.  Particu- 
larly should  all  delicate  children  and  those  with  any  tuberculous  tendency 
be  kept  from  exposure.  Quarantine  is  necessary  until  the  paroxysmal  stage 
is  past. 

In  the  treatment  of  the  disease  itself  hygienic  measures  are  most  im- 
portant. 


I02  THE    INFECTIOUS   DISEASES. 

The  patient  should,  as  a  rule,  be  kept  in  the  open  air,  especially  during  the 
warm  months.  Older  children  may  be  allowed  out  of  doors  on  pleasant 
days  even  in  winter.  Delicate  children,  however,  and  those  in  whom  there 
is  any  tendency  to  bronchitis  should  be  kept  in  doors.  Special  stress  should 
be  laid  upon  the  thorough  and  frequent  ventilation  of  the  apartments  occu- 
pied by  the  patient  and  frequent,  even  daily,  fumigation  by  means  of  a  forma- 
line candle  or  lamp.    The  bedding,  clothing,  etc.,  shovild  be  often  changed. 

In  protracted  instances  a  change  of  climate  is  indicated  and  delicate  children 
do  better,  especially  in  winter,  if  they  are  taken  to  a  warm  place.  The  sea 
shore  and  sea  voyages  are  often  beneficial. 

Internal  Treatment.  Of  the  almost  numberless  drugs  which  have  been 
recommended  in  whooping  cough  bromoform  is,  perhaps,  one  of  the  most 
effectual  but  must  be  employed  with  great  caution  as  cases  of  poisoning  have 
been  reported  from  its  use.  It  may  be  administered  in  the  following  formula : 
Bromoform,  i  part;  alcohol,  8  parts;  glycerin,  48  parts;  compound  tincture  of 
cardamom,  8  parts.  Each  drachm  (4.0)  contains  3  minims  (0.2)  of  bromoform 
which  may  be  given  to  a  child  of  two  years,  three  or  four  times  daily.  The 
mixture  should  be  carefully  made  and  must  be  shaken  immediately  before 
taking.     Bromoform  may  also  be  taken  dropped  upon  lumps  of  sugar. 

Antipyrine  is  a  useful  drug  but  should  not  be  given  if  heart  or  severe  pul- 
monary complications  are  present.  Its  dosage  for  a  two  year  old  child  is 
two  grains  (0.13)  5  or  6  times  a  day.  In  cases  with  particularly  marked 
paroxysms  antipyrine  may  be  advantageously  combined  with  sodium  bromide 
or  heroine. 

Quinine  has  enjoyed  much  vogue  in  the  treatment  of  pertussis.  Its  dosage 
for  a  child  of  two  years  should  be  about  three  grains  (0.2)  three  times  a  day; 
it  may  be  given  either  as  the  sulphate  or  the  hydrochloride.  It  is  important 
that  it  should  be  prescribed  in  palatable  form,  for  instance,  in  chocolate  covered 
tablets.  Its  great  disadvantage  is  its  liability  to  disturb  the  stomach  in 
infants  and  young  children;  this  fault  may  be  obviated  by  giving  the  drug  in 
enemata  or  in  suppositories.  The  treatment  should  begin  early  and  it  may 
be  wise  to  give  each  dose  directly  after  a  fit  of  coughing  since  at  this  time 
it  is  less  likely  to  cause  gastric  distiu-bance. 

Aristochine  (quinine  carbonic  ester)  has  no  bitter  taste  and  may  be  em- 
ployed instead  of  quinine.  Its  dose  is  i^  to  3  grains  (o.i  to  0.2)  three  times 
a  day.     Euquinine  is  another  substitute  for  quinine. 

In  belladonna  we  have  an  effectual  means  of  diminishing  the  number  and 
severity  of  the  paroxysms.  The  beginning  dose  should  be  small  and  gradually 
increased  until  physiological  effects  are  produced.  Its  action  must  be  care- 
fully observed  for  the  evidence  of  toxic  symptoms.  A  two  year  old  child 
may  receive  of  the  fluidextract  J  to  ^  a  drop  (0.016  to  0.032)  every  four  hours; 
atropine   in  doses  of  -5-^  of  a  grain  (0.00015)  may  be  substituted.      The 


WHOOPING    COUGH.  IO3 

above  doses  may  be  gradually  increased  in  size  or  given  at  gradually  dim- 
inished intervals  until  their  physiological  effect  as  evidenced  by  an  erythema 
of  the  skin  is  noted. 

Camphor  is  said  to  act,  not  only  as  a  stimulant  in  the  bronchitis  and  pneu- 
monia of  pertussis,  but  also  upon  the  disease  itself.  It  may  be  given  internally 
in  appropriate  doses. 

The  severity  of  the  nocturnal  attacks  may  be  lessened  by  sodium  bromide 
2  to  4  grains  (0.13  to  0.24),  or  by  codeine,  sulphonethylmethane  or  hydrated 
chloral;  the  latter,  however,  must  be  given  with  care.  Certain  clinicians 
rely  chiefly  upon  paregoric  to  check  the  paroxysms. 

In  general  it  may  be  said  of  the  drug  treatment  of  whooping  cough,  that 
since  the  disease  is  self-limited  and  since  in  all  probability  its  course  cannot 
be  shortened,  internal  medication,  in  patients  whose  paroxysms  are  neither 
distressing  nor  frequent,  should  be  postponed  until  the  cough  becomes  so 
marked  as  to  interfere  with  rest  and  the  bodily  functions.  When  this  event 
takes  place  medication  is  indicated. 

Local  treatment  by  means  of  sprays,  inhalations,  insufSations  of  various  powders 
and  by  direct  applications  to  the  larynx  may  be  prescribed.  Sprays  and  insuflQa- 
tions  probably  influence  the  disease  but  little,  but  may  be  useful  in  allaying  the 
catarrhal  symptoms  in  the  upper  air  passages.  As  sprays  a  solution  of  one 
of  the  more  soluble  quinine  salts,  Dobell's  solution,  liquor  antisepticus,  or  a 
mixture  containing  menthol  0.3  parts,  thymol  iodide  i  part,  oil  of  sweet  almonds 
25  parts  may  be  used.  Insufflations  such  as  the  following  may  be  employed: 
Benzoic  acid  and  bismuth  subsalicylate  each  10  parts,  quinine  sulphate  2 
parts,  or  powdered  antipyrine  and  quinine  hydrochloride  each  i  part,  boric 
acid  2  parts,  bismuth  subnitrate  5  parts.  Direct  applications  of  5  percent, 
cocaine  solution  may  be  made  to  the  larv^nx  in  older  children,  but  with  cau- 
tion. One  percent,  solutions  of  phenol  or  of  resorcinol  are  less  dan- 
gerous. The  applications  of  a  i  to  2  percent,  solution  of  formalin  to  the 
pharynx  has  been  advised.  Inhalations,  to  be  given  by  impregnating  the  air 
of  the  apartment  with  various  mixtures  or  by  means  of  an  inhaler,  are  some- 
times beneficial.  By  this  means  we  may  lessen  the  irritation  of  the  air 
passages  and  combat  the  tendency  to  bronchitis.  The  following  formulas 
are  applicable:  ^^ther,  chloroform  and  creosote  equal  parts;  to  be  used  upon 
the  cotton  or  sponge  of  a  respirator.  Phenol,  3  parts,  thymol,  5  parts,  alcohol, 
50  parts,  compound  tincture  of  lavender,  20  parts,  water  to  1000  parts;  to  be 
evaporated  over  an  alcohol  lamp. 

Inhalations  of  ethyl  iodide  are  said  to  afford  instant  relief  to  the  paroxysms 
and  to  lessen  the  severity  of  the  disease. 

The  spasm  of  the  glottis,  which  may  occur  when  the  spasms  of  coughing 
are  frequent  and  severe,  may  be  relieved  by  means  of  laryngeal  intubation. 
The  tube  may  remain  in  place  as  long  as  the  paroxysms  continue. 


I04  THE    INFECTIOUS    DISEASES. 

For  the  convulsions  a  few  whiffs  of  chloroform  may  be  given  and  as  an 
antispasmodic  a  plaster  of  asafcetida  applied  to  the  whole  chest  has  been 
suggested. 

A  20  percent,  solution  of  cypress  oil  in  alcohol  sprinkled  upon  the  patient's 
pillow,  the  upper  part  of  the  bed  and  upon  the  underclothing  several  times 
daily  is  said  to  benefit  the  cough. 

Lewriaux  has  produced  an  antitoxic  serum  by  inoculating  horses  with 
cultures  of  a  bacillus  which  he  has  isolated  from  cases  of  whooping  cough. 
In  his  hands  injections  of  from  75  to  150  minims  (5.0  to  lo.o)  of  this  serum, 
especially  if  given  early  in  the  disease,  have  acted  favorably. 

The  tendency  to  vomiting  may  be  lessened  by  applying  an  abdominal 
band  to  which  a  snugly  fitting  elastic  bandage  has  been  sewn.  To  young 
children,  in  whom  this  symptom  is  marked,  a  few  drops  of  the  camphorated 
tincture  of  opium  or  a  half  teaspoonful  (2.0)  of  a  mixture  of  dilute  hydrochloric 
acid  2  parts,  simple  syrup  200  parts,  lemon  spirit  2  parts,  may  be  given. 

The  sublingual  ulcer  should  be  kept  clean  by  the  use  of  mild  antiseptic 
mouth  washes  and  may  be  touched  from  time  to  time  with  a  3  percent,  solu- 
tion of  silver  nitrate.  Heart  weakness  calls  for  the  administration  of  alcohol 
and  strychnine. 

The  complicating  pneumonia,  bronchitis,  etc.,  may  be  treated  as  ordinarily. 

Throughout  the  disease  the  bowels  should  be  kept  freely  open  and  the 
patient  should  be  most  carefully  fed.  The  regulation  of  the  diet  is  often  a 
difficult  matter  since  vomiting  is  so  likely  to  occur,  but  is  most  important,  for 
digestive  disturbances  accentuate  the  severity  of  the  whooping  cough  and 
increase  the  frequency  of  the  paroxysms.  Young  infants  should  be  given 
diluted  milk  which  may  if  necessary  be  peptonized.  Older  children  should 
be  allowed  only  fluids,  chiefly  milk,  during  the  acuity  of  the  disease.  It  is 
essential  that  the  patient's  nourishment  be  thoroughly  maintained,  conse- 
quently vomited  meals  should  be  repeated. 

During  convalescence  the  administration  of  tonics,  especially  codliver  oil, 
the  syrup  of  iron  iodide  and  arsenic,  is  usually  necessary  since,  even  if  the 
infection  has  run  a  seemingly  uncomplicated  course,  the  patient's  system  is 
depreciated  and  his  powers  of  resistance  are  decreased,  owing  to  the  strain  to 
which  he  has  been  subjected. 

CEREBROSPINAL  FEVER. 

Synonyms.  Epidemic  Cerebrospinal  Meningitis;  Malignant  Purpuric  Fever; 
Petechial  Fever;  Spotted  Feyer. 

Definition.  An  acute  infectious  febrile  disease  occurring  sporadically 
and  in  epidemics  and  characterized  by  inflammation  of  the  membranes  of  the 
brain  and  spinal  cord  and  frequently  by  an  eruption  upon  the  skin. 


CEREBROSPINAL    FEVER.  I05 

Etiology.  Epidemics  of  this  disease  have  occurred  from  time  to  time 
in  the  United  States,  the  last  being  in  New  York  City  during  the  winter  of 
1904-5.  The  epidemics  are  usually  localized  and  seem  to  occur  rather  more 
often  in  the  country  than  in  cities  and  usually  in  the  winter  and  spring.  Un- 
sanitary conditions,  fatigue,  mental  and  physical  depression  and  the  asso- 
ciation of  large  numbers  of  persons  in  small  spaces,  such  as  army  camps  and 
barracks,  predispose  to  the  occurrence  of  the  disease. 

The  specific  cause  of  epidemic  meningitis  is  the  diplococcus  intracellularis 
meningitidis  which  is  found  within  the  bodies  of  the  polynuclear  leucocytes 
of  the  inflammatory  exudate.  With  this  micro-organism  other  bacteria,  such 
as  the  staphylococcus,  the  streptococcus,  the  pneumococcus,  the  bacillus 
coli,  etc.,  may  be  associated. 

Cerebrospinal  fever  is  probably  not  directly  contagious  in  that  the  infection 
is  transmitted  by  fomites  and  the  excretions  and  it  is  difl&cult  to  trace  the 
origin  of  a  certain  instance  of  the  disease  to  any  other,  irregular  distribution 
being  a  characteristic  of  the  affection.  The  contagium  is,  however,  supposed 
to  be  air  borne  and  to  reach  the  meninges  through  the  nose  by  means  of  the 
cribriform  plate  of  the  ethmoid  bone. 

Pathology.  The  skin  may  bear  the  remains  of  the  petechial  or  herpetic 
eruption  in  certain  instances  but  the  changes  in  the  nervous  system  are  more 
constant.  These,  however,  are  very  variable  in  degree  and  may  occur  as 
merely  slight  congestion  or  as  pronounced  hypera^mia  of  the  pia-arachnoid, 
with  fibrino-purulent  deposits,  especially  at  the  base  of  the  cerebrum,  result- 
ing in  a  coating  of  the  meninges  with  the  exudate.  The  upper  and  lateral 
surfaces  of  the  brain  may  also  be  involved  in  the  inflammatory  process.  The 
exudate  is  beneath  the  pia  mater  and  is  likely  to  be  more  profuse  in  the  longit- 
udinal fissures  and  Sylvian  fissures.  The  substance  of  the  brain  may  be 
congested  and  even  softened.  In  the  infections  of  long  standing  the  meninges 
are  thickened  and  adherent  to  the  cortex.  The  ventricles  are  filled  with 
sero-pus  and  in  prolonged  instances  of  the  disease  may  be  greatly  distended, 
their  walls  being  softened;  here  a  condition  of  hydrocephalus  may  sometimes 
be  met. 

The  cranial  nerves,  especially  the  optic,  the  facial  and  the  auditory,  are 
often  involved. 

The  spinal  meninges  are  involved  similarly  to  those  of  the  brain.  The 
exudate  is  most  profuse  upon  their  dorsal  surfaces  and  the  lower  segments 
are  chiefly  afifected.  The  spinal  and  the  central  canal  may  both  contain  pus 
in  considerable  amount.  The  cord  itself  may  be  inflamed  and  the  spinal 
nerve  roots  may  be  the  seat  of  a  neuritis  or  may  be  compressed  by  the  exudate. 

Microscopical  examination  shows  the  exudate  to  consist  of  polynuclear 
leucocytes  enmeshed  in  fibrin.  The  meningococci  are  found  both  within 
the  leucocytes  and  amongst  the  fibrin.     The  substance  of  the  brain  and  cord 


Io6  THE    INFECTIOUS    DISEASES. 

may  be  infiltrated  with  pus,  the  neuroglia  cells  are  swollen  and  haemorrhagic 
foci  may  be  present. 

The  lungs  may  be  the  seat  of  a  pneumonia  caused  by  the  diplococcus  pneu- 
moniae or  by  the  meningococcus.  Pulmonary  congestion  or  pleurisy  may  be 
observed. 

Endocarditis  sometimes  is  noted  and  the  congestion  of  the  various  viscera 
occurring  as  a  result  of  an  infectious  disease  is  usually  present.  The  spleen 
may  be  enlarged. 

Symptoms.  These  vary  with  the  type  of  the  disease.  The  incubation 
period  of  the  ordinary  form  is  not  known.  Its  onset  is  usually  sudden,  although 
there  may  be  a  short  prodromal  period  marked  by  dizziness,  headache  and 
pain  in  the  back.  The  invasion  is  often  evidenced  by  a  chill  and  vomiting  of 
the  projectile  type  followed  by  headache,  pain  in  the  back  of  the  neck  and  in  the 
lumbar  region.  These  symptoms  may  be  mild  or  very  severe.  The  muscles  of 
the  neck  are  stiff  and  movement  causes  an  increase  of  the  pain.  The  tempera- 
ture is  not  characteristic,  it  may  not  exceed  102°  F.  (38.9°  C.)  but  in  marked 
infections  it  may  reach  104°  to  106°  F.  (40°  to  41.1°  C.)  and  may  ascend 
even  higher  just  before  death.  Remissions  are  not  infrequent.  The  pulse 
in  adults  is  at  first  not  very  rapid  and  is  of  good  strength.  Later  it  becomes 
faster  and  weaker.  In  children  it  is  usually  rapid  from  the  outset.  In 
certain  instances  the  disease  is  characterized  by  a  pulse  of  not  over  60  or  70. 
In  the  absence  of  pulmonary  complications  the  respirations  are  not  much 
accelerated.     Cheyne-Stokes  respiration  is  sometimes  observed. 

The  symptoms  due  to  the  nervous  system  are  marked  and  of  early  appear- 
ance. The  skin  is  hyperaesthetic  and  the  muscular  rigidity  increases  as  the 
disease  progresses,  spasm  of  the  neck  muscles  draws  the  head  back  and  opistho- 
tonos may  be  present;  clonic  spasms  may  occur,  especially  in  children,  in  whom 
the  onset  may  be  marked  by  a  convulsion.  Strabismus,  nystagmus  and 
facial  contractions  are  common.  As  the  exudate  increases  the  symptoms  of 
pressure  paralysis  succeed  those  of  irritation  and  there  are  paralyses  of  the 
muscles  of  the  face  with  ptosis,  pupillary  inequality  and  rarely  paralysis  of  the 
muscles  of  the  body  and  limbs.  Of  symptoms  referable  to  the  special  senses 
photophobia,  diplopia  and  auditory  disturbances,  especially  intolerance  of 
sound,  are  often  present. 

Delirium  is  an  early  symptom  and  may  be  violent.  The  increase  in  intra- 
cranial pressure  later  results  in  stupor  and  finally  in  coma. 

The  skin  manifestations  are  important  although  the  eruption  is  by  no  means 
constantly  present.  Herpes  labialis  is  very  frequent  and  herpetic  eruptions 
may  appear  elsewhere  upon  the  face  as  well  as  upon  the  body  and  limbs. 
The  characteristic  rash  of  the  disease  is  petechial  and  often  general.  The 
number  of  spots  varies  greatly,  in  some  instances  only  a  few  being  noted, 
while  in  others  they  are  very  numerous.     They  do  not  disappear  on  pressure. 


CEREBROSPINAL    FEVER.  I07 

Other  rashes  such  as  erythema,  urticaria,  ecthyma,  erythema  nodosum, 
pemphigus,  and  spots  resembUng  those  of  enteric  fever,  may  occur.  Cutaneous 
gangrene  has  been  noted. 

The  tongue  is  at  first  moist  and  coated,  later  it  may  become  dry;  distressing 
vomiting  may  persist  throughout  the  disease.  The  bowels  are  usually  con- 
stipated but  at  times  a  diarrhoea  may  be  present  at  the  invasion. 

The  urine  is  usually  scanty,  high  colored  and  contains  albumin.  At  times 
it  is  increased  in  quantity  and  contains  glucose  as  a  result  of  the  pressure  of 
the  exudate  upon  the  cerebral  centers. 

Leucocytosis  is  a  constant  symptom  and  is  often  persistent. 

Kernig's  sign  is  constantly  present  here  as  in  all  other  conditions  in  which  there 
is  inflammation  of  the  spinal  meninges.  It  is  obtained  by  placing  the  patient 
in  a  sitting  position  with  the  thighs  flexed  at  the  hips  and  the  legs  partly  flexed 
at  the  knees.  The  observer  then  attempts  to  extend  the  leg  at  the  knee ;  this 
will  be  found  impossible  on  account  of  the  resistance  of  the  flexor  muscles. 
If  the  thigh  is  not  flexed  upon  the  abdomen  the  leg  can  be  straightened.  This 
phenomenon  is  explained  upon  the  ground  that  in  meningeal  inflammation 
the  spinal  nerve  roots  become  irritable  and  the  flexion  of  the  thighs  at  the 
hips,  when  the  patient  is  sitting,  tends  to  stretch  the  lumbar  and  sacral  roots 
and  increase  their  irritability. 

Babinski's  reflex,  a  turning  up  of  the  toes,  especially  the  great  toe,  conse- 
quent upon  tickling  the  sole,  is  not  constant. 

The  course  of  cerebrospinal  fever  is  very  variable;  death  may  occur  within  a 
few  hours  or  the  disease  may  be  prolonged  for  months.  Fatal  instances  usually 
die  within  the  first  week.  If  the  patient  survives  for  five  or  more  days  im- 
provement may  be  expected,  the  temperature  falls,  the  nervous  symptoms 
gradually  clear  and  convalescence  becomes  established.  This  period  is  usually 
long.     Relapses  are  not  uncommon. 

The  malignant  form  of  the  disease  is  very  sudden  in  its  invasion  and  while 
there  may  be  only  slight  rise  in  temperature  the  headache  and  nervous  symp- 
toms are  pronounced,  collapse  with  feeble  and  slow  pulse  and  labored  respi- 
ration ensues,  to  be  followed  by  death,  sometimes  within  24  hours.  A  haemor- 
rhagic  eruption  is  usually  present.  Such  infections  are  often  seen  at  the  be- 
ginning of  an  epidemic. 

A  mild  form  of  the  disease  sometimes  occurs  in  which  the  presence  of  an 
epidemic  gives  the  only  clue  to  diagnosis. 

The  abortive  form  is  evidenced  by  pronounced  and  severe  symptoms  at  its 
onset;  these  cease  suddenly  and  an  early  convalescence  is  established. 

The  intermittent  form  is  characterized  by  a  temperature  resembling  that  of 
pyaemia  and  which  exhibits  remissions  daily  or  every  other  day. 

The  chronic  form.  This  designation  is  applied  to  a  t)^e  of  the  disease 
in  which  the  course  may  be  prolonged  for  several  months.     The  patient  suf- 


Io8  THE    INFECTIOUS    DISEASES. 

fers  from  headache,  digestive  irritabihty,  marked  emaciation  and  exhaustion, 
and  remissions  of  the  fever. 

Complications.  Of  these  pneumonia  is  one  of  the  most  frequent  and  it 
may  be  difficult  to  determine  whether  it  or  the  meningeal  inflammation  is  the 
primary  disease.  In  the  presence  of  an  epidemic  the  problem  is  more  simple 
than  at  other  times,  and  when  the  headache,  pain  and  stiffness  in  the  back, 
and  nervous  symptoms  precede  other  manifestations,  the  chances  are  in 
favor  of  meningitis.  Pleurisy,  bronchitis,  endocarditis  and  parotid  inflam- 
mation may  occur.  Arthritis  is  a  common  complication  in  certain  epidem- 
ics. The  affection  is  usually  multiple  and  the  effusion  may  be  either  serous 
or  purulent. 

The  sequelcB  of  cerebrospinal  fever  are  numerous  and  often  serious.  Those 
referable  to  the  motor  nervous  system  are  facial  palsy  of  varying  extent  and 
paralyses  of  the  limbs;  these  may  be  permanent  but  are  usually  temporary 
only.  Sequelae  referable  to  the  organs  of  special  sense  are  optic  neuritis 
resulting  in  bhndness,  choroido-intis  and  keratitis;  labyrinthine  inflam- 
mation resulting  in  deafness,  otitis  media  and  its  complications.  Speech 
disturbances  may  occur  and  obstinate  headache  and  muscular  pains  have  been 
noted.  Chronic  hydrocephalus,  abscess  of  the  brain  and  mental  weakness 
have  deen  observed. 

The  diagnosis  during  epidemics  is  usually  not  difl5cult  but  the  recognition 
of  sporadic  cases,  especially  those  of  atypical  course,  is  sometimes  far  from 
easy.  The  diagnostic  symptoms  which  are  present  early  in  the  disease  are 
the  headache,  stiffness,  with  retraction  of  the  head,  of  the  muscles  of  the 
neck  and  back,  tremors  and  mental  disturbance,  especially  delirium.  Pneu- 
monia may  be  mistaken  for  meningitis  but  here  we  have  a  diminution  of  the 
urinary  chlorides,  an  absence  of  Kernig's  sign,  a  rapid  pulse  and  a  preponder- 
ance of  the  pulmonary  symptoms  over  those  referable  to  the  nervous  system. 
With  regard  to  the  general  differentiation  of  this  disease,  the  presence  of 
Kernig's  sign  is  an  important  point  and  the  result  of  lumbar  puncture  should 
usually  confirm  or  disprove  the  diagnosis.  This  operation  is  simple,  harmless 
and  needs  no  anaesthesia  beyond  that  obtainable  by  mean's  of  the  ethyl  chloride 
or  aether  spray,  or  at  most  a  few  breaths  of  chloroform.  The  patient  should 
lie  upon  the  right  side  with  knees  drawn  up  and  the  left  shoulder  turned  toward 
the  front.  An  aspirating  syringe  is  used,  the  needje  of  which  is  introduced 
one  centimeter  to  one  side  of  the  median  line  and  midway  between  the  third 
and  fourth  or  the  fourth  and  fifth  lumbar  vertebrae  below  the  spinous  process, 
the  thumb  being  placed  as  a  guide  between  the  spinous  processes.  The 
needle  should  be  directed  slightly  upward  and  inward,  and  at  a  depth  of  about 
two  centimeters  in  infants  and  from  four  to  six  in  adults,  should  enter  the 
canal.  The  syringe  now  being  detached  from  the  needle  the  fluid  is  allowed 
to  flow  into  a  sterile  test  tube.     From  i^  to  4  drachms  (6.0  to  16.0)  are  neces- 


CEREBROSPINAL    FEVER.  lOQ 

sary  for  chemical,  microscopical  and  bacteriological  examination.  The  fluid  in 
epidemic  meningitis  is  usually  turbid  and  may  contain  pus  or  blood;  that  in 
tuberculous  meningitis  is  clear  in  most  instances.  The  meningococcus  is 
often  present  in  the  fluid  of  epidemic  meningitis  in  considerable  numbers. 

The  prognosis  varies  in  different  epidemics  from  20  to  75  percent.  The 
mortality  is  very  high  in  the  prolonged  cases,  in  young  children  and  in  the 
aged.  The  initial  symptoms  give  no  index  of  the  probable  subsequent  course 
of  the  disease,  and  while  a  mild  invasion  may  be  followed  by  grave  symp- 
toms, a  severe  onset  may  be  succeeded  by  a  rapid  amelioration.  Convales- 
cence may  be  interrupted  by  recrudescences  or  relapses. 

Treatment.  Much  in  the  way  of  prevention  may  be  accomplished  by  the 
establishment  of  proper  ventilation,  drainage  and  general  sanitation. 

In  private  practice  the  patient  should  be  isolated,  in  order  to  secure  the  nec- 
essary quiet  as  well  as  to  prevent  contagion,  in  a  properly  ventilated  room 
which  need  not  be  darkened  since  bandaging  the  eyes  accomplishes  the  same 
purpose. 

The  old  method  of  treatment  by  blood-letting  is  seldom  employed  at  present 
but  the  pain  may  be  reheved  in  robust  patients  by  the  application  of  wet 
cups  to  the  back  of  the  neck;  the  use  of  the  ice  helmet  and  of  ice  bags  ap- 
plied along  the  course  of  the  spinal  cord  is  to  be  recommended,  and  while 
blistering  is  unnecessary,  touching  the  skin  of  the  nape  of  the  neck  with  the 
actual  cautery  may  be  beneficial.  Elevating  the  head  of  the  bed  often  makes 
the  patient  more  comfortable. 

The  plan  of  treatment  by  means  of  hot  bathing  as  advocated  by  Aufrecht 
is  said  to  accomplish  exceedingly  good  results.  A  hot  bath  at  104°  F.  (40°  C), 
lasting  from  15  to  20  minutes  is  given  once  or  twice  daily  or  even  oftener. 
An  ice  bag  is  applied  to  the  head  and  stimulants,  such  as  alcohol,  am- 
monia, etc.,  are  given  as  indicated.  While  the  temperature,  muscular 
rigidity  and  emesis  are  not  markedly  influenced  by  this  treatment,  it  is  asserted 
that  bathing  after  this  fashion  relieves  the  pain,  lessens  the  restlessness  and 
delirium  and  may  restore  consciousness.  Such  complications  as  endocarditis 
do  not  necessitate  the  intermission  of  this  treatment.  It  may  be  safely  stated 
with  regard  to  the  hot  bath  method,  that  it  does  no  harm,  may  benefit  the 
patient  and  may  exert  a  favorable  influence  upon  the  course  of  the  infection. 

Lumbar  puncture,  with  or  without  the  injection  of  antiseptic  fluids,  has 
been  employed  in  treatment  as  well  as  in  diagnosis,  by  many  clinicians.  The 
opinions  as  to  its  efl&cacy  differ  to  a  marked  degree.  It  may  be  asserted, 
however,  that,  even  though  the  procedure  may  not  be  curative,  it  does  relieve 
the  symptoms  due  to  pressure  and  is  worthy  of  employment  for  this  reason. 
The  technique  of  the  operation  has  already  been  described  (p.  108).  In 
instances  where  marked  pressure  symptoms  are  present  from  5  to  15  drachms 
(20.0  to  60.0)  may  be  withdrawn  and  the  procedure  repeated  if  necessary. 


no  THE    INFECTIOUS    DISEASES. 

Where  only  slight  evidence  of  pressure  is  manifest  not  more  than  5  to  7 J 
drachms  (20.0  to  30.0)  should  be  withdrawn. 

The  hot  bath  treatment  and  that  by  lumbar  puncture  may  be  employed 
in  connection  with  one  another. 

Of  the  solutions  for  intraspinal  injection,  following  the  withdrawal  of  fluid 
by  lumbar  punctm-e,  i  percent,  lysol  is  most  commonly  used.  From  two 
to  three  drachms  (8.0  to  12.0)  have  been  injected  with  yarying  results  in 
the  hands  of  different  clinicians.  Mercury  oxycyanide  solution  has  also 
been  employed.  This  form  of  treatment,  while  it  may  do  no  harm,  has,  tak- 
ing everything  into  consideration,  given  no  very  remarkable  results. 

The  fact  that  there  is  a  marked  antagonism  between  the  meningococcus 
and  the  Klebs-Loffler  bacillus  has  suggested  the  employment  of  diphtheria 
antitoxin  in  the  treatment  of  meningitis  but  unfortunately  the  results  obtained 
either  by  hypodermatic  or  intraspinal  injections  of  antidiphtheritic  serum 
have  not  been  sufficiently  good  to  establish  this  treatment  upon  a  firm  basis. 

The  subcutaneous  injection  of  mercury  bichloride  solution  along  the  course 
of  the  spinal  cord  has  been  recommended  by  several  authors.  The  adult 
dose  is  ^  of  a  grain  (o.oi)  and  that  for  children  from  y^-q-  to  -jV  of  a  grain 
(0.0005  to  0.005).  The  injections  are  well  borne  and  may  be  repeated  while 
the  temperature,  pain  and  muscular  stiffness  persist.  Angyan,  who  has 
reported  at  length  upon  this  form  of  treatment,  while  not  asserting  that  it 
influences  the  length  of  the  disease,  considers  that  by  its  use  the  symptoms 
are  favorably  affected. 

With  regard  to  the  general  management  of  epidemic  cerebrospinal  mening- 
itis and  the  relief  of  symptoms  the  following  points  may  be  given.  The 
bowels  should  be  kept  freely  open  throughout  the  disease  by  means  of  calomel 
given  in  divided  doses,  by  salines  or  by  enemata.  The  patient  should  be 
allowed  plenty  of  water  to  drink  which  will  increase  the  elimination  of  the 
toxins  through  the  kidneys.  In  instances  of  urinary  retention  the  use  of  the 
catheter  may  become  necessary. 

The  nose  and  throat,  which  are  often  inflamed,  should  be  sprayed  and 
irrigated  with  mild  alkaline  solutions  and  the  frequent  use  of  a  mouth  wash 
will  lessen  the  tendency  to  dryness  of  the  tongue.  In  instances  where  there  is 
dysphagia,  feeding  by  means  of  the  stomach  or  nasal  tube  or  by  rectum  should 
be  practised. 

For  the  vomiting  the  patient  should  be  given  bits  of  cracked  ice  to  suck, 
cold  should  be  applied  to  the  epigastrium  and  feeding  should  be  infrequent 
until  this  symptom  is  under  control.  In  obstinate  infections  the  use  of  mor- 
phine hypodermatically  may  become  imperative.  Vomiting  due  to  pressure 
upon  the  medulla  may  be  relieved  by  lumbar  puncture. 

The  nervous  symptoms  necessitate  the  employment  of  various  analgesics 
and  sedatives.     Cool  packs  and  tepid  baths,  to  which  mustard  may  be  added. 


ERYSIPELAS.  Ill 

often,  in  the  milder  infectionslessen  the  tendency  to  sensory,  motor  and  mental 
excitability  and  may  induce  sleep.  Antipyrine  is  often  effectual  in  checking 
the  headache  and  general  h^^eraesthesia  and  is  also  useful  in  lowering  the 
temperature  and  relieving  the  mental  excitability.  While  not  likely  to  cause 
cardiac  depression,  the  drug  should  be  given  with  care.  Acetphenetidine  may 
also  be  employed.  When  these  two  drugs  fail  to  control  the  nervous  symp- 
toms we  may  have  recourse  to  codeine  or  morphine.  The  bromides  likewise 
may  be  administered  in  this  connection.  For  the  convulsions  hydrated  chloral 
should  be  given  per  rectum  and  inhalations  of  chloroform  may  be  prescribed. 
Where  these  fail  hypodermatic  injections  of  morphine  should  be  given. 

In  the  later  stages,  where  cardiac  weakness  is  pronounced,  free  stimulation 
by  means  of  alcohol,  ammonia  and,  in  cases  of  collapse,  by  hypodermatic  injec- 
tions of  camphor  in  oil,  are  indicated.  Heart  weakness  may  also  be  combated 
by  means  of  high  hot  saline  irrigations  given  per  rectum  and  by  hypodermato- 
clysis  with  normal  saline  solution.  The  former  procedure  has  the  addi- 
tional advantage  of  assisting  in  the  elimination  of  toxins  through  the  kidneys, 
it  being  a  vigorous  diuretic. 

Various  drugs  have  enjoyed,  probably  undeservedly,  a  vogue  in  the 
treatment  of  this  disease.  Among  them  may  be  mentioned  ergot,  quinine, 
physostigma  and  belladonna. 

In  chronic  types  of  the  disease  and  in  those  which  are  left  with  meningeal 
thickenings  potassium  iodide  or  the  syrup  of  hydriodic  acid  should  be  given 
with  the  intent  to  induce  absorption. 

The  complications  and  sequelae  should  be  treated  as  when  occurring  as  a 
result  of  other  causes. 

The  importance  of  maintaining  nutrition  cannot  be  over -rated.  During 
the  acute  stage  the  diet  should  consist  of  milk,  broths,  gruels  and  other  fluids; 
later  semi-solids,  to  be  followed  by  ordinary  diet,  may  be  allowed.  The  use  of 
the  stomach  tube  may  be  necessary'. 

ERYSIPELAS. 

Synonym.     St.  Anthony's  Fire. 

Definition.  An  acute  febrile  contagious  disease  characterized  by  intense 
local  inflammation  of  the  skin,  a  remittent  temperature  and  a  tendency  to 
spread. 

.Etiology.  This  disease  is  common,  often  endemic,  and  from  time  to 
time  epidemic.  It  is  most  frequent  in  the  spring  months  and  is  very  likely 
to  break  out  in  old  and  improperly  kept  hospitals  and  institutions;  it  may 
occur,  however,  under  the  best  sanitary  conditions.  iPoor  general  condition, 
alcoholism  and  chronic  diseases  predispose  to  its  incidence  and  certain  indi- 
viduals seem  especially  prone  to  acquire  the  infection.     One  attack  does  not 


112  THE    INFECTIOUS    DISEASES. 

confer  immunity,  on  the  contrary  recurrences  are  frequent.  Women,  post- 
parhim,  and  the  subjects  of  recent  surgical  operations,  even  such  procedures 
as  cupping,  leeching  and  vaccination,  are  particularly  liable  to  acquire  the 
disease. 

The  contagium,  while  not  very  active,  may  be  transmitted  by  contact  with 
a  third  person  and  by  fomites,  bedding,  furniture,  etc.  While  a  solution  of 
the  continuity  of  the  skin  would  seem  to  be  a  necessary  antecedent  to  infection, 
idiopathic  cases  do  occur  in  which  no  such  manifestation  is  discoverable; 
in  such,  however,  it  is  impossible  to  state  that  a  microscopical  lesion  has  not 
existed,  although  the  possibility  that  the  contagium  may  reach  the  blood 
stream  by  means  of  the  respiratory  or  the  digestive  tracts  must  be  considered. 

The  specific  cause  of  erysipelas  is  a  bacterium,  the  streptococcus  erysipelatis, 
one  of  the  micro-organisms  of  the  streptococcus  pyogenes  group. 

Pathology.  The  inflammatory  redness  of  the  skin  in  erysipelas  does 
not  persist  post  mortem  but  oedema  and  abscesses  or  blebs,  if  they  have 
occurred,  are  left  behind.  Microscopic  examination  reveals  the  presence 
of  the  streptococci  in  the  lymphatics  and  lymph  spaces  at  the  margin  of  the 
inflamed  area;  they  may  be  demonstrated  in  the  lymph  vessels  of  the  structures 
beyond  the  affected  tissues  as  well.  Associated  lesions  are  metastatic  abscesses 
in  the  various  organs  and  haemorrhagic  infarcts  of  the  lungs,  kidneys  or  spleen. 
Secondary  septic  pleurisy,  pericarditis  or  endocarditis  may  be  present.  Acute 
nephritis  may  be  found;  meningitis  and  pneumonia  are  rare. 

Symptoms.  The  variety  of  erj^sipelas  which  usually  confronts  the  physician 
is  that  which  occurs  without  previous  discoverable  lesion  and  most  often 
involves  the  head  and  face.  The  incubation  period  is  given  by  various  authori- 
ties as  being  from  i  to  14  days.  The  onset  of  the  disease  is  usuaUy  marked 
by  one  or  more  chills,  malaise  and  anorexia,  followed  by  a  rise  of  tem- 
perature. If  the  point  at  which  infection  has  taken  place  is  discoverable 
it  becomes  red,  a  reddened,  burning  spot  appearing  usually  upon  the  bridge 
of  the  nose  or  upon  the  chin.  This  rapidly  increases  in  size,  becoming  elevated 
with  a  distinctly  palpable  margin,  smooth,  brawny,  oedematous  and  hot  to 
the  touch.  The  skin  feels  tense  to  the  patient  and  the  inflammation  spreads 
rapidly  toward  the  forehead  and  ears,  closing  the  eyes,  thickening  the  lips  and 
ears  and  distorting  the  features.  Blebs  form  upon  the  ears  and  eyelids; 
these  contain  serum;  the  neck  is  rarely  involved  but  the  cervical  glands  are 
swollen  and  there  is  marked  leucocytosis.  In  the  severe  types  deep  abscesses 
may  form.  The  inflammation  as  it  extends  gradually  diminishes  in  the  parts 
first  affected,  lasting  about  four  days  in  one  spot.  If  its  progress  becomes 
limited  the  temperature  falls  by  crisis  and  the  symptoms  disappear.  Recur- 
rences are  not  rare.  With  the  fever  the  pulse  is  rapid,  there  are  headache 
and  sometimes  cerebral  symptoms,  the  constitutional  manifestations  being 
due  to  the  toxaemia  resulting  from  the  growth  of  the  bacteria  in  the  organism. 


ERYSIPELAS.  II3 

Severe  infections,  which  are  not  uncommonly  met  in  aged>  debilitated  and 
alcoholic  patients,  are  characterized  by  marked  prostration,  cerebral  symp- 
toms and  the  appearance  of  the  so-called  "typhoid  state"  in  which  death 
may  occur. 

The  mucous  membranes  of  the  mouth,  pharynx  and  larynx  may  be  involved 
by  extension  from  the  skin,  and  laryngeal  oedema  may  ensue.  Albuminuria 
is  common  and  haematuria  has  been  observed. 

Protracted  infections  may  be  met  in  which  the  inflammation  wanders  from 
one  part  to  another,  gradually  involving  the  whole  body. 

Complications  are  not  common  although  such  conditions  as  septic  inflam- 
mations of  the  pleura,  pericardium  and  endocardium,  bronchitis,  pneumonia 
and  nephritis  do  occur. 

Meningitis  is  very  rare,  septicaemia  and  pyaemia  are  more  often  seen. 

The  diagnosis  is  usually  easy,  the  constitutional  and  local  manifestations 
being  quite  characteristic. 

The  prognosis  in  robust  persons  is  good,  the  debilitated,  those  addicted 
to  alcohol,  infants  with  erysipelas  due  to  infection  at  the  umbilicus,  and  the 
aged  furnishing  the  great  majority  of  the  fatalities. 

Treatment.  With  regard  to  prophylaxis  it  may  be  stated  that  isolation 
is  a  necessity,  especially  in  hospitals.  Surgeons  and  those  engaged  in 
obstetrical  practice  should  not  attend  cases  of  erysipelas.  Frequent  baths 
with  boric  acid  solution  (5  percent.)  will  remove  the  desquamating  epidermis 
and  the  bed  and  body  linen  should  be  changed  at  least  once  daily. 

The  patient  should  be  kept  in  bed  upon  a  liquid  diet  and  the  channels  of 
elimination  should  be  kept  freely  open  by  means  of  plenty  of  fluids  to  drink  and 
laxatives  when  necessary.  If  here  is  headache  and  severe  general  pain  such 
analgesics  as  antipyrine  saHcylate,  gr.  x  (0.66)  or  acetphenetidine,  gr.  x  (0.66) 
may  be  prescribed.  The  cerebral  symptoms,  if  present,  may  be  controlled  by 
cool  or  tepid  sponge  baths,  by  the  bromides  or  by  morphine  hypodermatically. 
In  feeble  patients  stimulation  by  means  of  alcohol  and  strychnine  may  be 
employed  as  indicated. 

It  is  doubtful  if  internal  medication  can  influence  the  infection  in  any  way 
but  the  tincture  of  iron  chloride  is  prescribed  by  many  in  the  hope  that  in  some 
way  it  may  exert  a  specific  action.  A  drachm  (4.0)  every  three  hours  may  be 
given  but  a  smaller  dose — 10  drops  (0.66) — will  probably  do  the  work  quite 
as  well. 

Injections  of  antiseptic  solutions  into  the  skin  just  beyond  the  margin  of  the 
inflammatory  area  have  been  practised  and  seem  to  have  a  rational  basis 
for  their  employment.  Two  percent,  phenol  solution  or  1-4,000  mercury 
bichloride  solution  may  be  used. 

Of  local  applications  that  most  popular  at  present  is  an  ointment  or  solu- 
tion of  ichthyol  of   10  percent,  strength,  applied  upon  gauze  and  renewed 


114  THE    INFECTIOUS    DISEASES. 

several  times  daily.  An  ointment  containing  i  part  of  phenol,  lo  parts 
of  ichthyol  and  20  parts  of  lanolin  is  also  recommended.  Moist  dressings 
of  I  percent,  phenol,  i  to  1,000  mercury  bichloride,  equal  parts  of  ichthyol, 
glycerin,  and  water,  i  to  1,000  potassium  permanganate,  and  dusting  with 
equal  parts  of  bismuth  benzoate  and  starch  have  been  suggested. 

In  the  umbilical  infection  of  the  new-born,  ichthyol  in  10  percent,  solution 
or  ointment  or  an  ointment  of  irV  part  of  mercury  bichloride,  10  parts  of 
cerate  of  lead  subacetate  and  40  parts  of  vasehne  may  be  applied. 

The  use  of  Crede's  ointment  may  be  followed  by  good  results.  It  should 
be  well  rubbed  into  the  skin  just  beyond  the  inflammation. 

The  suggestion  to  lightly  scarify  the  part  before  applying  moist  antiseptic 
dressings  would  seem  reasonable  since  by  this  means  the  germicide  is  able  to 
come  into  closer  contact  with  the  infective  micro-organisms  in  the  tissues. 

Various  observers  have  employed  injections  of  antistreptococcus  serum; 
the  results  reported  have  in  many  instances  been  favorable  and  it  is  quite 
possible  that  further  experimentation  with  this  treatment  may  establish  it 
as  a  routine  method.  This  form  of  treatment  does  not  seem  to  shorten  the 
disease  but  the  injection  of  5  drachms  (20.0)  of  the  serum  in  one  or  two  doses 
is  said  to  lessen  the  severity  of  the  symptoms  and  to  cause  a  disappearance 
of  the  albuminuria. 

The  diet  during  the  febrile  stage  should  be  of  fluids  only  and  as  highly 
nutritious  as  possible  in  order  to  maintain  the  patient's  strength  and  powers 
of  resistance. 

During  convalescence  the  dietary  should  still  be  carefully  regulated  and  the 
administration  of  tonics,  such  as  strychnine,  iron  and  quinine  is  strongly 
indicated. 

ACUTE  ARTICULAR  'RHEUMATISM. 

Synonyms.  Rheumatic  Fever;  Inflammatory  Rheumatism;  Acute  Rheu- 
matism. 

Definition.  An  acute  infectious  febrile  disease  characterized  by  inflam- 
mation of  one  or  more  of  the  joints. 

.Etiology.  The  disease  is  most  common  during  the  cold  and  damp 
months  and  in  young  adults,  especially  those  of  low  vitality  and  whose  occupa- 
tions expose  them  to  the  inclemencies  of  weather.  Extremes  of  cold  are  less 
likely  to  predispose  to  the  disease  than  a  moderately  low  temperature  accom- 
panied by  moisture.     An  hereditary  tendency  to  the  disease  has  been  noted. 

It  is  probable  that  the  infection  is  the  result  of  specific  bacterial  intoxi- 
cation, although  thus  far  no  causative  germ  has  been  isolated.  Various 
observers  have,  however,  cultivated  from  the  inflammatory  exudates  of  rheu- 
matic patients  different  micro-organisms  which  are  capable  of  causing  arthritis 


ACUTE    ARTICULAR    RHEUMATISM.  II5 

and  endocarditis  in  lower  animals.  Several  distinct  species  of  bacteria  have 
been  isolated  from  rheumatic  exudates  which  fact  goes  to  show,  as  suggested  by 
Flexner  and  Barker,  that  perhaps  acute  articular  rheumatism  may  be  the  re- 
sult of  infection  of  the  blood  by  any  one  of  several  species  of  pathogenic  micro- 
organisms at  a  time  when  circumstances  are  such  as  not  to  favor  the  develop- 
ment of  general  septicaemia  but  are  favorable  to  the  propagation  of  inflam- 
matory conditions  of  one  or  more  of  the  serous  membranes. 

Various  forms  of  arthritis  simulate  acute  articular  rheumatism,  such  as 
those  complicating  other  acute  infectious  diseases,  notably  scarlatina,  and 
the  arthritis  due  to  the  gonococcus.  These  are  not  true  rheumatisms  but 
inflammations  of  the  synovial  membranes  due  to  other  causes. 

Pathology.  The  affected  joint  is  swollen,  hot,  sometimes  red,  and  is  bathed 
in  acid  perspiration. 

Its  synovial  lining  is  congested  and  swollen.  The  joint  cavity  is  sometimes 
distended  by  fluid.  This  is  usually  serous  but  may  be  turbid,  or  rarely  puru- 
lent. The  cartilages  within  the  joint  and  covering  the  articular  surfaces 
may  be  eroded. 

Symptoms.  The  onset  of  the  disease  is  usually  rapid,  one  or  more  joints 
becoming,  even  within  a  few  hours,  swollen, ,  painful,  tender,  reddened  and 
bathed  in  perspiration.  Less  frequently  there  is  a  short  period  of  invasion 
during  which  the  patient  has  indefinite  pains  in  bones  and  joints.  The  onset 
is  rarely  marked  by  a  chill,  but  is  usually  followed  by  a  rise  in  temperature. 
The  regular  course  of  the  infection  lasts  about  six  weeks  but  with  proper 
treatment  we  are  usually  able  to  shorten  the  acute  stage  to  six  or  seven  days. 
With  the  inception  of  the  disease  there  is  often  nausea  and  vomiting.  The 
temperature  rises  to  io2°-io4°  F.  (38.9°  to  40°  C).  The  pulse  is  accelerated 
(95  to  100),  the  urine  is  scanty,  high  colored  and  acid  with  a  copious  sediment 
of  urates;  it  may  contain  albumin;  the  bowels  are  usually  constipated. 
The  febrile  movement  continues  while  the  joints  are  acutely  inflamed  but 
frequently  is  of  remittent  type. 

The  skin  is  usually  bathed  in  an  acid  perspiration  and  it  may  be  the  seat  of 
various  eruptions.  These  may  be  erythemata,  diffuse  papular,  tubercular 
or  marginate,  urticaria,  or  a  true  purpura  with  hasmorrhagic  spots  of  varying 
size.  Sloughing  may  follow  these  last  and  with  them  there  may  be  haemor- 
rhages from  the  various  mucous  membranes  and  haematuria.  This  condition  is 
denominated  peliosis  rheumatica  and  is  of  doubtful  rheumatic  origin.  Nodules 
of  various  sizes  up  to  that  of  a  pea  have  been  observed  in  certain  patients  in 
the  tendons  and  muscle  sheaths  of  the  extremities,  limbs  and  even  over  the  ver- 
tebrae. These  are  a  feature  of  the  declining  stage  of  the  disease;  they  are 
more  usually  seen  in  children  and  remain  from  several  days  to  several 
weeks. 

The  pain  is  usually  very  severe,  any  movement  increases  it  and  even  the 


ii6 


THE    INFECTIOUS    DISEASES. 


weight  of  the  bed  clothing  may  cause  extreme  discomfort.  The  patient  finds 
that  the  pain  is  least  when  the  joints  are  held  in  a  position  of  mid-flexion. 

Usually  more  than  one  joint  is  inflamed  and  those  most  often  attacked 
are  the  knee,  ankle,  wrist,  elbow,  shoulder  and  hip,  in  the  order  named.  The 
joints  of  the  fingers  are  not  exempt.  Rarely  is  a  single  joint  affected, 
though  this  may  occur.  The  inflammation  has  a  tendency  to  involve  succes- 
sively one  joint  after  another,  the  symptoms  in  one  being  to  some  extent 
relieved  as  another  is  attacked.  At  times  the  process  wifl  recur  in  a  joint 
which  has  partially  returned  to  normal. 

A  patient  who  has  once  suffered  from  rheumatic  fever  is  prone  to  recur- 


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Fig.  6. — Clinical  chart  of  acute  articular  rheumatism. 


rences  of  the  disease  at  intervals  of  from  one  to  several  years,  and  it  is  these 
successive  attacks  which  are  likely  to  result  in  serious  complications,  more 
especially  in  the  heart. 

Hyperpyrexia.  In  certain  patients  the  temperature  may  rise  to  a  very  high 
level  even  to  iio°  F.  (43.3°  C).  Such  a  condition  is  a  very  serious  one  and 
generally  results  in  death  unless  the  fever  can  be  quickly  reduced.  With 
this  excessive  temperature  are  other  symptoms  of  marked  constitutional 
disturbance,  such  as  headache,  delirium,  unconsciousness  and  heart  failure. 

Complications.  These  affect  the  serous  membranes  and  the  endocardium 
and  are  the  result  of  the  lodgment  of  the  infectious  material  in  the  blood 
in  these  situations.  The  pleura,  the  pericardium  and  more  rarely  the  peri- 
tonaeum are  the  membranes  involved  and  their  inflammations  are  amenable 


ACUTE    ARTICULAR    RHEUMATISM.  II7 

to  anti-rheumatic  treatment.  In  rheumatic  pleurisy  physical  signs  are  con- 
spicuously absent,  an  important  point  in  differential  diagnosis. 

Endocarditis  is  a  frequent  and  most  dreaded  complication,  its  usual  seat 
is  in  the  left  side  of  the  heart  and  it  is  less  likely  to  attack  the  aortic  than  the 
mitral  valve.  The  heart  should  be  the  subject  of  very  frequent  examination 
since  in  even  mild  rheumatic  infections  it  may  become  the  seat  of  valvular 
disease  of  severe  type.  The  proportion  of  heart  complications  in  this  disease 
is  stated  by  some  authorities  to  be  as  high  as  sixty  percent.  The  onset  may 
be  gradual  and  difficult  of  diagnosis,  while  dyspnoea  and  palpitation  may 
appear  as  features  of  a  rheumatic  attack  with  merely  a  functional  cardiac 
disorder.  The  endocarditis  is  more,  frequently  seen  in  youthful  patients 
and  is  usually  of  the  vegetative  type.  The  heart  may  regain  its  normal 
condition  but  most  of  the  cases  of  chronic  endocarditis  seen  in  practice  are 
the  result  of  rheumatic  infection. 

Infective  or  malignant  endocarditis  may  occur,  but  inflammations  of  the 
myocardium  are  believed  to  be  rare. 

In  consideration  of  the  sequela?  of  acute  rheumatism,  chorea,  exophthalmic 
goitre  and  acute  nephritis,  and  the  permanent  joint  changes  similar  to  those 
of  chronic  articular  rheumatism  and  arthritis  deformans,  should  be  men- 
tioned. 

The  prognosis.  Recovery  is  usual  in  non-complicated  cases.  The  dura- 
tion of  the  acute  stage  of  the  disease  when  untreated  is  about  16  days  but 
with  proper  treatment  this  may  be  much  shortened.  In  many  instances  the 
infection  leaves  the  patient  with  a  permanently  impaired  heart.  Rarely  the 
patient  passes  on  to  the  condition  known  as  chronic  rheumatism. 

Death,  when  it  takes  place,  is  usually  the  result  of  hyperpyrexia  or  cardiac 
complications. 

Prophylaxis.  Persons  subject  to  the  disease  should  avoid  excessive  mus- 
cular exertion  and  especially  exposure  to  cold  and  wet.  Their  clothing 
should  be  warm,  preferably  of  woolen  next  to  the  skin  in  winter  and  of  linen 
during  the  hot  months.  Too  much  carbohydrate  food  and  malt  beverages 
should  be  avoided,  and  the  liver  and  bowels  should  be  kept  active.  Daily 
baths,  cold,  preferably,  if  well  borne,  should  be  taken  in  order  to  keep  the 
skin  active  and  healthy.     Out-door  life  and  proper  exercise  are  important. 

Treatment.  The  patient  should  be  kept  in  bed,  upon  a  soft  mattress 
and  covered  with  blankets,  not  sheets.  Calomel  followed  by  a  saline  should 
be  administered  and  the  bowels  should  be  kept  freely  open  during  the  whole 
course  of  the  disease. 

Medicinal  Treatment.  The  sahcylates  are  an  exact  chemical  limitant  of 
the  action  of  the  causative  bacteria,  but  the  problem  is  to  administer  these  in 
sufficient  dosage  to  accomplish  our  object  without  injury  to  the  heart,  stomach 
or  kidneys.     Salicylic  acid  and  sodium  salicylate,  especially  the  former,  are 


Il8  THE    INFECTIOUS    DISEASES. 

very  likely  to  disturb  the  stomach,  and,  being  eh'minated  through  the  kidneys, 
these  organs  are  likely  to  receive  harm.  The  acid  in  large  doses  diminishes 
the  contractile  povi^er  of  involuntary  muscle  fibre  and  consequently  its  admin- 
istration may  result  in  acute  cardiac  dilatation.  The  ideal  drug  would  be  an 
organic  combination  of  the  salicly  radical  which  would  pass  through  the  stomach 
unchanged  to  be  spilt  up  in  the  intestines.  Sixty  to  eighty  grains  (4.0  to  5.33)  per 
day  of  the  salicyl  radical  are  necessary  to  cause  a  disappearance  of  the  symptoms 
within  a  week  and  so  great  a  quantity  is  likely  to  be  harmful,  and  certainly 
is  objectionable,  to  the  patient.  The  problem  being  to  bring  the  salicylate  into 
direct  contact  with  the  joint  in  as  great  a  quantity  as  possible  and  to  prevent 
its  getting  into  the  circulation,  the  following  ointment  is  prescribed:  I^  acidi 
salicylici,  olei  terebinthinae,  adipis  lanae  hydrosi,  of  each  one  drachm  (4.0), 
unguenti,  q.s.  ad  one  ounce  (30.0).  Sig.  Rub  one  drachm  (4.0)  thoroughly  into 
the  diseased  joint  twice  a  day.  The  fact  that  a  curative  quantity  of  the  salicyl 
radical  is  absorbed  may  be  proven  by  finding  salicyluric  acid  in  the  urine 
within  20  minutes  after  an  inunction.* 

The  acutely  painful  and  tender  joint  of  beginning  acute  rheumatism  may 
cause  the  patient  to  rebel  against  this  form  of  treatment  but  the  administration 
of  salophen  (two  drachms — 8.0 — in  divided  doses  during  24  hours)  or  antipyrine 
salicylate  in  like  quantity  will  ease  the  pain  so  that  the  inunctions  may  be 
employed. 

During  the  administration  of  salicylic  acid  in  any  form  the  urine  should 
be  examined  daily  and  the  quantity,  specific  gravity,  and  presence  or  absence 
of  albumin  or  casts  noted.  It  should  be  remembered  that  salicyluric  acid 
reduces  Fehling's  solution,  consequently  such  a  reaction  should  not  be  mis- 
understood. 

The  above  treatment  usually  results  in  the  disappearance  of  the  acute 
symptoms  of  the  disease  within  a  week. 

In  hospital  practice  the  use  of  sodium  salicylate — grains  xx  (x.33) — and 
sodium  or  potassium  bicarbonate — grains  x  (0.66) — every  four  hours  will  be 
found  to  be  attended  with  excellent  results  but  in  privtae  practice  such  dosage 
is  objectionable  for  obvious  reasons.  The  alkali  may  be  diminished  when 
the  reaction  of  the  urine  becomes  alkaline.  With  this  form  of  treatment 
it  is  very  necessary  that  the  bowels  be  kept  freely  open,  that  water  be  drunk 
copiously  and  that  the  condition  of  heart  and  kidneys  be  carefuly  watched. 
When  the  acute  symptoms  of  the  disease  have  abated  the  dosage  should  be 
diminished.  Certain  authorities  advocate  the  use  of  salicin,  phenyl  salicylate 
(salol)  or  methyl  salicylate  (oil  of  wintergreen)  but  these  drugs  seem  to  have 
no  advantage  over  those  above  mentioned. 

Certain  feeble  and  anaemic  patients  are  not  benefited  by  the  alkalies    or 

♦Test  for  salicyluric  acid:  To  a  test  tube  of  urine  add  10  drops  of  the  tincture  of  ferric 
chloride  and  in  the  presence  of  salicyluric  acid  a  port  wine  color  will  result. 


ACUTE    ARTICULAR    RHEUMATISM.  II9 

salicylates  and  in  these  iron,  codliver  oil,  potassium  iodide  and  other  tonics 
and  alteratives  are  indicated. 

In  gouty  patients  an  attack  of  acute  rheumatism  seems  to  be  best  treated 
by  a  combination  of  colchicum  and  the  salicylates. 

When  the  salicylates  are  too  disturbing  to  the  stomach  they  may  be  given 
per  rectum  in  dosage  of  20  to  40  grains  (1.33  to  2.66)  in  solution  every  four 
or  six  hours. 

If  larger  doses  are  injected  it  is  wise  to  add  a  few  drops  of  tincture  of  opium. 

Acetyl-salicylic  acid  (aspirin)  is  recommended  as  a  substitute  for  the  more 
commonly  used  salicylates,  chiefly  because  it  passes  unchanged  through  the 
stomach,  causing  no  disturbance  to  this  organ,  and  is  split  up  in  the  bowel; 
its  taste  is  less  unpleasant  and  it  is  less  likely  to  cause  tinnitus.  Its  dosage 
is  from  ten  to  fifteen  grains  (0.66  to  i.o)  in  powder  or  capsule  every  three  or 
four  hours. 

It  may  be  said  in  conclusion  that  while  various  other  drugs  have  their 
advocates  the  general  consensus  of  opinion  is  that  in  salicylic  acid  and 
sodium  salicylate  we  have  the  most  efficacious  treatment  for  acute  rheumatism. 
Disadvantages  they  have  it  is  true,  such  as  their  tendency  to  disturb  the  stomach, 
heart  and  kidneys  and  to  produce  tinnitus  aurium  (which  may  be  relieved  by 
sodium  bromide),  or  even  deafness,  and  while  their  use  does  not  prevent  relapse 
possibly  because  their  administration  is  not  long  enough  continued,  nor  heart 
complications,  it  does  relieve  the  pain  quickly  and  effectively,  enables  the 
patient  to  sleep  and  causes  the  fever  to  fall  within  a  few  days. 

With  regard  to  hyperpyrexia,  energetic  cold  bathing — 70°  F.  (21.1°  C.) — or 
cold  packs  are  the  only  means  of  treatment  which  have  given  good  results. 
While  the  patient  is  being  moved  to  undergo  either  of  these  procedures  mor- 
phine may  be  given  hypodermatically  to  control  the  pain  and  strychnine 
or  alcohol  may  be  used  to  counteract  any  tendency  toward  collapse. 

The  treatment  of  other  complications,  pericarditis,  endocarditis,  etc.,  will 
be  dealt  with  in  the  sections  upon  these  diseases. 

While  the  febrile  movement  and  the  other  acute  symptoms  persist 
the  diet  should  be  of  milk,  soups  and  semi-solids.  A  return  to  ordinary  diet 
should  not  be  allowed  for  at  least  a  week  after  the  subsidence  of  the  joint 
symptoms. 

Menzer  has  prepared  a  serum  from  streptococci  from  the  tonsils  of  rheu- 
matic patients  and  has  used  it  in  more  than  30  instances  with  the  following  re- 
sults :  The  treatment  caused  no  pain  or  other  local  reaction  as  a  rule.  A  general 
reaction,  chilliness,  fever,  and  skin  eruptions,  often  resulted.  The  dose  used 
was  from  i^  to  5  ounces  (50.0  to  150.0).  He  believes  that  in  acute  instances 
the  course  of  the  disease  was  shortened,  and  he  particularly  states  that  the 
treatment  seemed  definitely  to  prevent  severe  endocarditis. 

Local  applications  of  various  kinds  may  relieve  the  joint  pain  and  swelling. 


I20  THE    INFECTIOUS    DISEASES. 

The  affected  parts  should  be  swathed  in  cotton  covered  by  oiled  silk  which 
will  protect  from  traumatism  and  maintain  an  even  temperature.  Often 
immobilization  by  means  of  splints  and  the  use  of  sand  bags  and  pillows  will 
add  to  the  comfort  of  the  patient.  It  is  to  be  remembered  in  the  application 
of  splints,  etc.,  that  mid-flexion  is  the  proper  position  in  which  to  place  the 
joint.  Blisters  of  cantharides  may  relieve  the  pain  in  the  acute  stage  and 
are  often  useful  later  in  the  disease.  Care  should  be  taken  lest  their  action 
be  carried  too  far.  Injections  of  lo  to  15  drops  (0.66  to  i.o)  of  i  percent, 
solution  of  phenol  beneath  the  skin  of  the  joint  are  advocated.  These  may 
be  repeated  once  or  twice  daily  and  are  said  to  relieve  the  pain  to  a  considerable 
extent.  Painting  with  tincture  of  iodine  or  applications  of  iodine  ointment 
are  likely  to  accomplish  little,  but  a  10  to  20  percent,  ointment  of  ichthyol  in 
lanolin  is  highly  recommended.  If  wet  dressings  are  applied  the  temperature 
should  be  warm.  Among  the  most  efficacious  of  these  is  Fuller's  lotion 
(sodium  carbonate  6  parts;  laudanum  80  parts;  glycerin  16  parts;  water 
72  parts),  equal  parts  of  guaiacol  and  glycerin;  fluid  extract  of  belladonna 
20  drops  (1.33)  to  the  ounce  (30.0)  of  glycerin;  and  oil  of  wintergreen.  These 
should  be  applied  upon  gauze  compresses  and  renewed  twice  daily. 

After  the  acute  stage  is  over  the  joints  will  be  much  benefited  by  properly 
applied  massage  and  passive  motion;  warm  and  steam  baths  and  galvanic 
electricity  will  also  be  found  useful. 

SEPTICAEMIA  AND  PYEMIA. 

Synonym.     Bacteriaemia. 

Definition.  Septicaemia  and  pyaemia  are  febrile  diseases  caused  by  the 
existence  in  the  blood  of  pathogenic  micro-organisms  and  characterized  by 
recurring  chills  and  irregular  rises  and  falls  of  temperature.  From  these 
affections  saprsemia  or  toxaemia  are  to  be  differentiated,  the  latter  being  the 
result  of  the  local  development  of  bacteria  and  the  taking  up  by  the  blood 
of  the  toxic  products  of  their  growth.  The  distinguishing  mark  of  pyaemia 
is  the  occurrence  in  the  various  tissues  and  organs  of  metastatic  pus  foci; 
in  septicaemia  this  manifestation  does  not  take  place. 

^Etiology.  Surgical  septicaemia  is  usually  considered  to  be  a  result  of 
infection  by  pyogenic  micro-organisms,  particularly  staphylococci  and  strep- 
tococci, while  to  the  physician  the  term  septicaemia  signifies  a  condition  caused 
by  the  presence  of  any  variety  of  pathogenic  micro-organism  in  the  blood  and 
tissues  while  a  demonstrable  focus  of  infection  may  or  may  not  be  present. 

The  basis  of  pyaemia  is  analogous  to  that  of  septicaemia  with  the  added 
factors  of  thrombosis  and  embolism.  To  these  latter  the  occurrence  of  the 
metastatic  abscesses  is  due.  For  instance,  a  septic  phlebitis  may  occur  with 
the  formation  of  an  infective  thrombus  from  which  bits  of  infectious  matter 


SEPTICEMIA    AND    PYiEMIA.  121 

may  become  detached  and  may  be  borne  as  emboli  by  the  blood  current  until 
their  linal  lodgment  in  a  vessel  the  lumen  of  which  is  too  narrow  for  their 
passage.  Here  such  infectious  particles  become  stationary  and  set  up  inflam- 
matory processes  which  soon  become  abscesses.  An  example  of  this  often  occurs 
in  infective  or  malignant  endocarditis  in  which  bits  of  the  valvular  vegetations 
may  become  detached  and  carried  as  emboli  by  the  circulation,  until,  lodging 
in  some  perhaps  remote  part  of  the  body,  they  result  in  abscesses. 

Emboli  from  septic  processes  in  the  periphery  and  in  the  bone-marrow 
are  most  likely  to  lodge  in  the  lungs,  those  from  the  tissues  drained  by  the 
portal  system,  in  the  liver,  those  from  the  female  organs  of  generation,  in  the 
pelvic  tissues,  those  from  the  left  side  of  the  heart  and  those  whose  size  permits 
of  passage  from  the  right  side  of  the  heart  through  the  pulmonary  circulation 
to  the  left  heart,  in  the  brain,  kidneys  or  spleen. 

Of  the  more  common  varieties  of  septicaemia  puerperal  infection  due  to 
retained  secundines,  lacerated  cervix  or  perinaeum,  scarlatinal  or  erysipelas 
infection  and  the  process  which  may  result  in  severe  forms  of  enteric  fever, 
gonorrhoea,  diphtheria  and  other  acute  infectious  diseases,  should  be  men- 
tioned. 

Symptoms.  Before  the  appearance  of  constitutional  symptoms,  those  of 
the  primary  local  lesion,  if  such  is  present,  will  be  noticed.  The  onset  of 
the  septicaemia  or  pyaemia  is  usually  marked  by  a  severe  chill  during  which 
the  temperature  may  rise  to  103°  to  105°  F.  (39.4°  to  40.5°  C).  Following 
this  manifestation  there  is  profuse  sweating  succeeding  which  the  temperature 
may  rise  again.  Chills,  rises  of  temperature  and  sweats  succeed  one  another 
at  intervals  of  one  or  two  days,  a  general  tendency  of  the  fever  to  be  higher 
at  night  being  not  unusual.  The  patient  is  prostrated,  thirsty,  suffers  from 
anorexia  and  nausea,  and  perhaps  vomits.  Flesh  is  rapidly  lost,  exhaustion 
becomes  profound  and  a  condition  of  semi-coma  may  supervene;  transient 
erythematous  eruptions  may  appear. 

Local  symptoms  are  frequent  in  pyaemia  and  are  due  to  the  lodgment  of 
the  septic  emboli.  In  the  lungs  these  cause  pain,  rapid  respiration  and  cough; 
in  the  liver,  pain  with  tenderness,  enlargement  of  the  organ  and  jaundice; 
in  the  subcutaneous  tissues,  pain,  tenderness  and  swelling,  followed  by  abscess 
formation;  in  the  joints,  the  usual  signs  of  inflammation  and  the  presence  of 
intra-articular  effusion;  in  the  kidneys,  albumin  or  blood  in  the  urine.  Emboli 
lodging  in  the  brain,  unless  they  shut  off  the  blood  supply  of  portions  of  this 
organ  essential  to  the  performance  of  the  body  fimctions,  are  not  likely  to 
be  suspected.  Emboli  of  the  spleen  cause  pain  in  the  side,  tenderness  and 
splenic  enlargement,  while  metastatic  abscesses  of  the  pancreas  are  evidenced 
by  deep  pain  and  tenderness  in  the  region  of  that  organ. 

The  diagnosis  of  septicaemia  and  pyaemia  usually  offers  little  difficulty 
when  a  primary  focus  is  present.     When  this  aid  is  absent  blood  examination 


122  THE    INFECTIOUS    DISEASES. 

will  reveal  a  considerable  leucocytosis  and  cultures  may  show  the  presence 
of  the  causative  micro-organism.  Enteric  fever  may  be  differentiated  by 
means  of  the  Widal  reaction  and  malaria  by  examination  of  the  blood  and  by 
the  test  of  quinine  treatment.  Gonorrhoea  and  prostatic  abscess,  as  well  as 
tuberculous  nephritis  and  pyelitis  due  to  the  presence  of  calculi,  may  be 
factors  in  causation.  In  malignant  endocarditis  a  murmur  is  usually  present 
but  both  this  condition  and  acute  osteo-myelitis  may  be  unsuspected. 

The  prognosis  is  always  serious  in  pyaemic  conditions.  Puerperal  septi- 
caemia is  the  least  grave  type  of  the  affection  if  proper  treatment  is  instituted. 
Chronic  infections  may  last  for  months  with  irregular  temperature  and  grad- 
ually increasing  anaemia  and  emaciation  until  death  supervenes. 

Treatment.  Much  may  be  done  in  the  way  of  prevention  of  puerperal 
septicaemia  by  proper  cleansing  of  the  patient's  genital  tract,  the  physician's 
hands  and  instruments,  the  complete  removal  of  the  contents  of  the  uterus 
and  proper  after-treatment  of  cervical,  vaginal  and  perinaeal  lacerations. 
Crede  recommends  the  sterilization  of  the  patient's  genitals  after  parturition 
by  first  removing  all  clots,  etc.,  and  then  inserting  a  vaginal  suppository  con- 
sisting of  i^  grains  (o.i)  each  of  powdered  talc  and  coUargol  and  30  grains 
(2.0)  of  cocoa  butter;  the  vagina  is  then  packed  loosely  with  sterile  gauze 
which  later,  with  the  introduction  of  another  suppository,  may  be  renewed. 
If  infection  takes  place  douches  of  i  to  2,000  to  i  to  5,000  collargol  solution  are 
given  and  if  there  is  any  retention  of  placenta  or  membranes  these  should 
be  removed  by  operation.  In  advanced  infection  the  intravenous  injection  of 
2  to  2^  drachms  (8.0  to  lo.o)  of  collargol  solution  is  advised.  This  last  pro- 
cedure may  also  be  employed  in  septicaemia  and  pyaemia  of  other  forms. 

The  early  treatment  of  sepyticaemic  and  pyaemic  states  by  surgical  means 
is  most  important.  The  primary  focus  should  be  rendered  thoroughly  clean 
by  means  of  antiseptics,  the  curette  or  even  the  actual  cautery.  All  collections 
of  pus  which  can  be  reached  should  be  opened  and  drained  and  even  ampu- 
tation of  a  limb  may  be  necessary.  Subcutaneous  injections  of  antiseptics 
into  the  tissues  may  be  given  just  as  has  been  recommended  in  erysipelas 
(p.  113).  The  bowels,  kidneys  and  skin  should  be  kept  active  in  order  that 
the  poisons  may  be  eliminated  in  so  far  as  is  possible  and  this  may  be  furthered 
by  the  administrations  of  high  rectal  irrigations  of  hot  sahne  solution  given 
two  or  three  times  daily  and  two  to  four  gallons  (8  to  16  litres)  at  a  time. 

The  temperature  may  be  relieved  by  sponging  with  cool  water  and  quinine 
sulphate  may  be  given  in  doses  of  15  to  30  grains  (i.o  to  2.0)  daily.  If  the 
coal  tar  antipyretics  are  employed  much  caution  is  necessary  because  of 
their  depressing  effect.  The  sweating  may  be  controlled  by  jq  of  a  grain, 
(0.006)  of  morphine  with  -5-^  of  a  grain  (0.0006)  of  atropine,  by  agaricin 
one  to  two  grains  (0.065  to  0.13),  or  dilute  sulphuric  acid  15  to  30  drops  (i.o 
to  2.0). 


HYDROPHOBIA,  1 23 

Tincture  of  iodine  20  to  25  drops  (1.33  to  1.66)  daily  in  divided  doses, 
given  in  syrup  or  rice-water  is  recommended  and  inunctions  of  Crede's  oint- 
ment may  be  employed.  Intravenous  injections  of  collargol  solution  as 
advised  above  may  be  tried.  Stimulation  by  means  of  alcohol  and  strych- 
nine is  always  indicated  and  in  the  later  stages  hypodermoclyses  of  hot  normal 
saline  solution  may  become  necessary 

Treatment  by  means  of  antistreptococcus  serum  should  never  be  omitted, 
especially  in  severe  infections;  5  to  7^  drachms  (20.0  to  30.0)  may  be  injected 
every  six  to  eight  hours,  the  doses  being  diminished  as  improvement  is  mani- 
fested. 

The  diet  throughout  should  be  of  the  most  nutritious  and  easily  digestible 
character  and  of  plentiful  amount, 

HYDROPHOBIA. 

Synonyms.    Rabies;  Lyssa, 

Definition.  An  acute  speciiic  infectious  disease  to  which  all  warm-blooded 
animals  are  subject.  It  is  communicable  to  man  by  inoculation  and  is 
characterized  by  tonic  spasms  usually  beginning  at  the  larynx. 

Etiology.  The  dog  is  particularly  prone  to  this  disease  and  when  the 
affection  occurs  in  man  it  is  usually  through  the  bite  of  this  animal.  Hydro- 
phobia is  also  seen  in  wolves,  cats,  skunks  and  even  cows  and  may  be  inocu- 
lated into  rabbits,  horses  and  other  domestic  animals. 

While  undoubtedly  the  result  of  infection  with  a  micro-organism,  the  specific 
cause  of  the  disease  has  not  been  isolated.  The  toxic  substance  exists  in  the 
central  nervous  system  and  in  certain  secretions,  particularly  the  saliva,  by 
means  of  which  it  is  usually  transmitted. 

By  no  means  all  the  individuals  bitten  by  rabid  dogs  suffer  from  hydropho- 
bia. Horseley  gives  the  figures  as  15  percent.,  while  the  mortality  among 
those  bitten  by  wolves  is  much  larger,  being  from  40  to  80  percent.  Children 
more  frequently  suffer  from  the  disease  than  adults  and  bites  upon  the  face 
and  hands,  probably  because  these  parts  are  more  often  unprotected  by 
clothing  which  may  wipe  off  the  saliva  before  the  teeth  of  the  animal  reach 
the  tissues,  are  more  likely  to  be  followed  by  hydrophobia  than  those  upon 
other  parts.  Punctured  wounds  are  considered  especially  likely  to  be  serious. 
It  is  certain  that  many  cases  reported  as  hydrophobia  are  in  reality  not 
this  disease  at  all  and  some  go  so  far  as  to  assert  their  skepticism  as  to  its 
existence  as  a  nosological  entity. 

Pathology.  The  characteristic  morbid  changes  present  in  hydrophobia 
are  microscopical  and  are,  so  far  as  is  known,  confined  to  the  nervous  system, 
the  rabic  virus  likewise  is  present  in  the  brain,  cord  and  peripheral  nerves 
but  is  not  found  in  other  organs  and  tissues.     The  pathological  conditions 


124  THE    INFECTIOUS    DISEASES. 

consist  of  a  dilatation  of  the  vessels  of  the  brain,  medulla  and  upper  cord  and 
a  collection  of  leucocytes  in  the  peri-vascular  sheaths  and  about  the  nerve 
cells,  particularly  those  of  the  motor  ganglia.  Van  Gehuchten  and  Nelis 
have  described  certain  alterations  in  the  peripheral  ganglia  of  the  cerebro- 
spinal and  sympathetic  systems  consisting  of  a  proliferation  of  the  normal 
cellular  elements  which  tends  later  to  destruction  and  a  replacement  by 
round  cells.  Analogous  changes  are  observed  in  certain  other,  diseases  as  ■ 
botulismus  and  diphtheria. 

In  1903  Negri  described  as  constantly  present  in  the  nerve  cells  of  rabetic 
animals,  certain  bodies,  which  he  believed  to  be  protozoa,  and  which  varied 
in  size  and  shape  according  to  their  position  in  the  cell.  They  are  found 
especially  in  the  cells  of  the  hippocampus  major  and  have  been  observed  also 
in  the  cells  of  the  pons,  in  Purkinje's  cells  and  in  cells  in  other  situations.  A 
number  of  different  opinions  exists  as  to  the  character  of  these  bodies  and 
also  as  to  their  diagnostic  value. 

Inasmuch  as  there  are  no  pathological  appearances  which  are  universally 
admitted  to  be  characteristic  of  the  disease,  the  diagnosis  must  remain  uncer- 
tain. Many  instances  of  tetanus,  septicaemia  and  tuberculous  meningitis 
have  been  reported  as  hydrophobia.  Of  fifteen  consecutive  deaths  ascribed 
to  hydrophobia  and  so  recorded  by  the  New  York  City  Department  of  Health 
not  one,  after  careful  investigation,  could  fairly  be  ascribed  to  this  cause. 

Symptoms.  The  period  of  incubation  is  from  six  weeks  to  two  months 
although,  rarely,  symptoms  have  been  reported  as  appearing  within  two 
weeks  after  the  infection,  and  incubations  of  a  year  or  more  have  been  observed. 

The  symptoms  of  the  attack  may  be  divided  into  three  stages.  Of  these 
the  first  or  premonitory  stage  is  characterized  by  local  manifestations  about 
the  bite,  such  as  pain,  tenderness  and  redness.  The  patient's  mentality  is 
depressed,  he  suffers  from  headache,  anorexia  and  insomnia;  he  is  feverish 
and  perhaps  melancholic  and  anxious.  Any  sudden  noise  or  flash  of  light  is 
startling.  The  voice  is  hoarse,  the  larynx  may  be  congested  and  there  may 
be  dysphagia. 

The  spasmodic  stage  follows  the  stage  of  premonition  after  about  24  hours. 
The  patient  is  most  excitable,  restless  and  hypergesthetic.  Any  peripheral 
irritation,  even  a  sound  or  draught  of  air,  brings  on  a  pronounced  reflex 
spasm.  This  affects  chiefly  the  muscles  of  the  throat  and  larynx  and  is 
particularly  likely  to  be  induced  by  the  act  of  swallowing.  The  spasm  is  pain- 
ful and  is  accompanied  by  marked  dyspnoea.  The  fact  that  the  spasm  is  so 
closely  associated  with  the  act  of  deglutition  causes  the  dread  of  water.  The 
saliva  is  usually  increased  and  cannot  be  swallowed  without  causing  a 
paroxysm.  Maniacal  excitement  may  accompany  the  spasm  and  restraint 
may  be  necessary,  but  in  the  intervals  the  patient  is  quiet,  his  mentality  is 
normal  and  he  appears  anxious  lest  he  do  harm  during  the  seizures. 


HYDROPHOBIA.  1 2  5 

The  temperature  is  elevated — from  101°  to  103°  F.  (38.5°  to  39.6°  C.) — 
and  the  pulse  is  accelerated.  This  stage  lasts  from  one  to  three  days  and  is 
succeeded  by 

The  paralytic  stage.  This  is  characterized  by  exhaustion  upon  the  part 
of  the  patient;  he  becomes  quiet  and  gradually  comatose.  The  cardiac  action 
becomes  weaker  and  weaker  and  death  supervenes  in  syncope. 

The  diagnosis  is  not  particularly  diflficult,  the  history  and  the  length  of  the 
incubation  period  being  important  differential  points. 

Pseudo-hydrophobia  or  lyssophobia  may  closely  simulate  true  rabies. 
This  condition  is  likely  to  follow,  particularly  in  neurotic  individuals,  the  bite 
of  an  animal  and  it  may  even  be  characterized  by  paroxysms  very  like  those 
of  hydrophobia.  The  patient's  symptoms  usually  ameliorate  upon  treat- 
ment although  their  duration  is  longer  than  in  true  rabies.  The  disease  does 
not  progress  nor  is  there  a  rise  of  temperature.  The  diagnosis  of  hydrophobia 
may  be  assured  by  inoculating  rabbits  or  guinea  pigs  with  bits  of  the  medulla 
of  the  supposedly  rabid  animal;  the  animals,  if  true  rabies  is  present,  will  within 
15  to  20  days  develop  the  paralytic  type  of  the  disease.  It  is  advisable,  how- 
ever, to  inoculate  a  second  series  of  animals,  since  various  drugs  such  as  strych- 
nine and  atropine  are  capable  of  producing  symptoms  identical  with  those 
of  dumb  rabies.  The  changes  in  the  peripheral  ganglia  of  the  cerebrospinal 
and  sympathetic  nervous  systems  of  the  affected  animal  are  also  character- 
istic. These  may  be  examined  and  the  diagnosis  determined  within  a  few 
hours  after  the  animal's  death;  he  must,  however,  die  a  natural  death.  The 
ganglion  of  the  vagus  nerve  is  usually  examined  and  shows  a  proliferation 
and  finally  destruction  of  the  normal  cells  and  a  replacement  by  round  cells. 
It  must  be  remembered  that  Marinesco  has  shown  that  identical  changes  occur 
in  sausage  poisoning  (infection  with  the  bacillus  botulismus)  and  analogous 
ones  are  met  in  tetanus  and  diphtheria. 

Supposedly  rabid  animals  should  not  be  killed  unless  absolutely  necessary, 
but  should  be  confined  in  order  to  ascertain  if  they  are  certainly  affected  with 
the  disease. 

The  prognosis  in  fully  developed  infections  is  distinctly  bad,  the  patient 
dying  usually  in  from  two  to  six  days.  Cauterization  of  the  bite  and  the 
Pasteur  treatment,  when  undertaken  in  time,  are  very  effectual. 

Treatment.  Prevention  of  rabies  is  easily  accomplished  by  the  syste- 
matic muzzling  of  all  dogs. 

The  bite  having  been  inflicted  the  wound  should  be  at  once  sucked,  prefer- 
ably by  the  patient  himself,  and  the  mouth  immediately  washed.  Cauteri- 
zation with  a  red  hot  iron,  the  Paquelin  or  the  galvano-cautery  should  be 
practised  as  soon  as  possible.  Failing  these  means  stick  silver  nitrate,  pure 
phenol  or  potassium  hydrate  should  be  employed;  the  wound  should  not  be 
allowed  to  heal. 


126 


THE  INFECTIOUS  DISEASES. 


The  Pasteur  treatment  is  a  method  of  prevention  based  upon  incompleted 
experiments  made  by  the  distinguished  French  scientist  whose  name  is  imme- 
diately suggested  by  the  word  hydrophobia.  It  is  founded  upon  his  discovery 
that  the  poison  of  this  disease  has  its  seat  in  the  nervous  system,  especially 
in  the  brain,  medulla  and  cord.  By  inoculation  of  virus  from  the  nervous 
tissues  of  rabid  animals  through  a  series  of  50  rabbits  a  virus  is  produced 
which  acts  after  an  incubation  period  of  7  days.  This  is  termed  "fixed 
virus."  The  spinal  cords  of  the  last  rabbits  of  such  series  contain  this  virus 
in  great  intensity  but  its  potency  is  quickly  reduced  by  exposure  of  the  cords 
to  dry  air,  consequently  they  are  dried  in  sterile  glass  vessels  with  potassium 
hydrate.  In  dogs  inoculated  with  an  emulsion  made  from  fragments  of  medulla 
of  diminished  virulence  and  then  with  preparations  of  cord  of  higher  potency 
immunity  from  inoculation  by  fresh  cord  substance  is  reduced.  Working 
on  this  basis  Pasteur  inoculated  human  subjects,  who  had  been  bitten,  with 
emulsion  of  two  weeks  old  cords  and  on  each  successive  day  to  the  number 
of  12  gave  other  inoculations  until  those  but  one  day  old  were  used.  By  this 
treatment  he  succeeded  in  rendering  the  individual  immune.  At  present 
the  method  employed  in  most  Pasteur  institutes  consists  in  giving  inoculations 
from  cords  of  increasing  virulence  in  rather  more  rapid  successions.  Below 
is  given  a  tabulated  statement  of  the  results  of  this  treatment  at  the  institute 
in  Paris. 


Year. 

Persons 
Treated. 

Deaths. 

Percent,  of 

Mortality. 

1886 

2,671 
1,770 
1,622 
1,830 
1,540 

1.559 
1,790 
1,648 

1.387 
1,520 
1,308 
1,521 
1,465 
1,614 
1,420* 

1.321 
1,105 

25 
14 

9 

7 

5 

4 

4 

6 

7 
5 
4 
6 

3 

4 

4* 

5 
2 

0.94 
0.79 

0-55 
0.38 
0.32 
0.25 

1887 

1888 

1880 

1800 

1801 

1802 

180^ 

0.36 
0.50 

0-33 
0.30 

0-39 

1804 

1805 

i8q6 

1807 

i8q8 

i8qq 

0.25 

0.35* 
0.38 
0  18 

1000 

IQOI 

IQ02 

During  1902,  one  thousand,  one  hundred  and  six  persons  were  treated,  of 
whom  three  died  from  hydrophobia.    Inasmuch  as  in  one  instance  the  disease 

*  Corrected  to  1,420,  5,  and  0.35  respectively. 


TETANUS.  127 

declared  itself  before  the  end  of  treatment,  this  is  excluded  from  both  "  persons 
treated"  and  "deaths." 

The  time  necessary  for  the  treatment  is  15  days,  two  inoculations  being 
given  daily  to  ordinary  patients.  To  those  whose  treatment  has  been  insti- 
tuted late  or  in  whom  the  wounds  are  upon  the  face  or  head  four  to  six  inocu- 
lations per  day  may  be  given. 

The  following  is  a  condensation  of  the  instructions  published  by  the  insti- 
tute at  New  York,  for  the  benefit  of  those  bitten  by  supposedly  rabid  animals. 

Cauterization  should  be  practised  as  soon  after  the  bite  as  possible.  Late 
cauterization  is  without  benefit  and  possesses  the  disadvantage  of  inducing 
a  false  sense  of  security.  The  bite  should  be  treated  in  other  respects  just 
like  any  infected  wound. 

The  patient  should  be  immediately  sent  to  the  institute,  since  each  day  of 
delay  renders  the  prognosis  less  favorable.  The  inoculation  is  harmless 
and  it  is  better  to  inoculate  before  learning  the  result  of  the  biological  diagnosis 
even  though  we  treat  those  who  do  not  possess  the  disease.  The  inoculation 
has  the  advantage  of  conferring  immunity  which  persists  for  several  years. 

The  dog  or  other  animal  should  be  confined  and  kept  under  observation 
until  it  dies  or  recovers,  and  notes  of  its  condition  and  progress  should  be 
sent  to  the  institute.  If  it  is  impossible  to  keep  the  animal  alive  it  should  be 
killed,  its  head  should  be  severed  with  a  sterile  knife,  a  portion  of  the 
medulla  removed,  and  placed  in  a  sterile  bottle  containing  a  previously  boiled 
mixture  of  equal  parts  of  glycerin  and  water.  This  bottle  should  be  sealed 
and  sent  to  the  institute  for  examination  and  inoculation.  A  report  upon  the 
stomach  contents  of  the  animal  should  also  be  forwarded  to  the  institute. 

After  the  onset  of  the  symptoms  they  should  be  controlled  in  so  far  as  possible. 
The  patient  should  be  placed  in  a  darkened  and  quiet  room  in  charge  of  two 
attendants.  While  the  milder  sedatives  such  as  the  bromides  and  chloral 
may  be  effectual  at  first  in  overcoming  the  nervous  irritability,  it  is  wiser  to 
employ  inhalations  of  chloroform  and  hypodermatic  injections  of  morphine 
from  the  beginning.  The  difficulty  in  swallowing  may  be  relieved  by  the 
local  use  of  cocaine  but  it  is  often  necessary  to  administer  both  food  and 
drink  by  means  of  the  rectal  tube. 

TETANUS. 

Synonyms.     Lockjaw;  Trismus. 

Definition.  An  acute  infectious  disease  characterized  by  repeated  tonic 
muscular  spasms  of  increasing  intensitv. 

.Etiology.  Tetanus  occurs  in  human  beings  and  in  lower  animals  and 
is  the  result  of  the  growth  within  the  organism  of  a  specific  micro-organism, 
the  bacillus  of  tetanus.     This  bacillus  is  found  in  the  soil,  especially  in  tropical 


128  THE    INFECTIOUS    DISEASES. 

countries,  in  the  intestines  of  ruminant  animals  and  in  their  excreta,  in  the 
fluids  of  putrefying  wounds  and  in  pus.  Its  portal  of  entry  is  usually  by 
means  of  a  wound,  especially  one  of  the  hand  or  foot  and  a  punctured  or 
contused  wound  rather  than  one  due  to  incision.  While  idiopathic  tetanus 
may  occur,  in  most  instances  a  thorough  search  will  reveal  a  slight  loss  of 
continuity  of  the  skin  which  has  afforded  entry  to  the  bacillus.  Tetanus 
may  occur  as  a  result  of  umbilical  infection  in  the  new-born  and  before  the 
introduction  of  antiseptic  dressings  was  a  frequent  cause  of  death  of  negro 
infants  in  the  West  Indies.  The  wound  of  the  blank  cartridge  of  the  Fourth 
of  July  toy  pistol  frequently  results  in  tetanus,  not,  however,  from  any  infec- 
tive character  of  the  charge  of  the  weapon. 

The  disease  is  predisposed  to  by  exposure  to  cold  and  wet  and,  while  it 
affects  all  ages  and  both  sexes,  is  more  common  in  males.  Epidemics  have 
been  occasionally  met. 

The  symptoms  are  not  the  result  of  the  presence  of  the  bacilli  in  the  blood, 
for  these  remain  and  develop  at  the  site  of  the  wound;  the  toxins  produced 
by  their  growth  are  responsible  for  the  constitutional  manifestations. 

Some  years  ago  a  large  number  of  infections  was  reported  as  being  caused  by 
injection  of  diphtheria  antitoxin  but  investigation  proved  that  these  were 
due  to  antitoxin  from  one  source  only,  and  that  the  substance  had  not  been 
prepared  under  proper  precautions. 

Pathology.  There  are  no  characteristic  morbid  changes  in  this  disease. 
The  wound  is  in  no  way  typical  and  while  granular  degeneration  of  the 
nerve  cells,  inflammatory  conditions  of  the  nerves,  and  congestion,  extrava- 
sations and  exudates  of  various  parts  have  been  found,  these  are  neither  co'n- 
stant  nor  essential. 

Symptoms.  The  usual  incubation  period  is  about  lo  days.  The  onset 
of  the  disease  may  be  marked  by  a  chill  or  chilly  sensations  but  this  is  not  the 
rule,  the  initial  symptoms  being  stiffness  of  the  neck  and  jaw;  mastication 
is  difficult  but  not  painful.  The  muscles  of  the  abdomen,  back  and  limbs 
become  gradually  stiff  and  the  body  becomes  so  inflexible  that  it  may  be 
raised  as  if  made  of  a  single  piece  of  wood  {orthotonos).  In  marked  instances 
it  may  be  impossible  to  force  the  jaws  apart.  Risus  sardonicus  may  be 
present  as  evidenced  by  a  drawing  out  of  the  corners  of  the  mouth  and  eleva- 
tion of  the  eyebrows;  paralysis  of  the  muscles  of  the  face,  dysphagia  with 
laryngeal  and  oesophageal  spasm  may  be  noted;  this  is  the  so-called  head 
tetanus  of  Rose  and  usually  is  the  result  of  a  wound  of  the  head  with  injury 
to  the  fifth  nerve. 

Paroxysms  may  be  induced  by  a  touch,  a  breath  of  air  or  any  slight  noise; 
during  these  the  muscles  of  the  trunk  contract,  producing  arching  of  the 
back  so  that  the  body  is  supported  by  the  head  and  heels  {opisthotonos),  or 
the  body  may  be  bent  forward  in   the  position  of  emprosthotonos  or  side- 


TETANUS.  I2g 

ways  in  the  posture  of  pleurosthotonos.  The  tongue  may  be  bitten  in  spasms 
of  the  jaw  or,  in  marked  instances,  the  chest  may  be  so  compressed  by  mus- 
cular contraction  as  to  cause  severe  pain  and  rapid  respiration.  The  opening 
of  the  larynx  may  be  contracted  producing  a  condition  of  asphyxia.  Extreme 
pain  is  an  accompaniment  of  the  paroxysm  and  the  body  may  be  bathed  in 
perspiration.  Between  the  attacks,  which  occur  at  intervals  varying  from 
a  few  minutes  to  several  homrs,  the  patient  may  be  able  to  walk  about  but  the 
relaxation  is  not  complete. 

Usually  the  temperature  is  only  slightly  above  normal  but  may  rise  to 
io6°  F.  (41.1°  C.)  or  to  110°  F.  (43.4°  C.)  or  even  higher  just  before  death, 
which  may  occur  diiring  a  paroxysm,  from  asphyxia  or  cardiac  failure,  or  from 
exhaustion.  The  pulse  and  respiration  are,  as  a  rule,  accelerated.  The 
mind  remains  clear.  Constipation  is  frequent  and  often  serious  since  attempts 
at  relief  are  likely  to  induce  the  paroxysm. 

The  diagnosis,  particularly  in  traumatic  tetanus,  is  usually  not  difficult; 
trismus  occurs  in  tetanus  but  not  in  hydrophobia,  and  in  strychnine  poisoning 
in  the  intervals  of  the  paroxysms  there  is  no  rigidity  and  the  convulsive  attacks 
affect  the  limbs  more  than  in  tetanus.  Bacteriological  tests  may  be  employed 
to  assure  the  diagnosis. 

The  prognosis  in  traumatic  tetanus  is  bad,  the  mortality  being  about  80 
percent,  as  against  less  than  50  percent,  in  the  idiopathic  form.  Death 
usually  takes  place  within  six  days  after  the  onset;  patients  surviving  longer 
than  this  period  are  likely  to  recover.  The  disease  is  especially  fatal  in 
children.  A  prolonged  incubation  period  is  a  favorable  sign  as  are  also  a 
localization  of  the  spasms  in  the  face  and  neck  and  an  absence  of  elevation 
of  temperature. 

Treatment  consists  first  in  thorough  cleansing  and  cauterization  of  the 
wound.  Particularly  should  all  bits  of  wadding,. powder,  etc.,  be  removed 
from  blank  cartridge  wounds;  the  actual  cautery,  phenol  or  silver  nitrate 
should  then  be  used  and  the  wound  dressed  antiseptically.  Dusting  the 
wound  with  powdered  tetanus  antitoxin  has  been  suggested,  and  a  prophv- 
lactic  injection  of  at  least  5,000  units  of  antitoxin  should  be  given  The  patient 
should  be  placed  in  a  darkened  room,  as  far  removed  from  irritant  influences 
as  possible;  he  should  receive  no  visitors,  one  attendant  being  sufficient, 
and  the  strictest  quiet  should  be  enjoined. 

While  the  results  obtainable  from  antitoxin  treatment  are  not  all  that  could  be 
hoped,  injections  should  be  instituted  in  all  instances.  It  has  been  shown  that 
the  route  of  the  tetanus  toxin  to  the  nerve  centers  is  along  the  motor  nerves  and 
less  directly  through  the  blood  and  lymphatics,  and  since  only  that  portion  of 
the  toxin  which  is  in  the  blood  and  tissues  outside  the  nerves  can  be  reached, 
the  antitoxin  should  be  injected  directly  into  the  veins  and  into  the 
tissues  about  the  focus  of  infection.  The  diagnosis  having  been  made  by 
9 


I30 


THE  INFECTIOUS    DISEASES. 


means  of  bacteriological  tests,  injections  should  be  immediately  begun  and 
continued  daily  for  at  least  two  weeks  from  date  of  the  injury.  The  in- 
jections should  be  into  the  median  basilic  vein  and  each  dose  should  consist 
of  from  2j  to  5  drachms  (lo.o  to  20.0).  It  is  better  to  give  too  large  doses 
than  too  small.  Intra-neural  injections,  the  motor  nerves  supplying  the 
injected  region  having  been  exposed  as  near  the  spinal  cord  as  possible,  of 
from  5  to  20  minims  (0.33  to  1.33)  are  advised  in  connection  with  the  above 
treatment.  The  cauda  equinae  may  also  be  injected  by  means  of  lumbar  punc- 
ture, certainty  that  the  injection  has  been  given  directly  into  its  nerves  being 
evidenced  by  twitchings.  In  urgent  instances  the  injections  may  be  given 
directly  into  the  cord  itself  at  the  level  of  the  sixth  or  seventh  cervical  seg- 
ment, the  risk  of  injury  being  less  than  that  of  the  spread  of  the  infection. 
After  these  more  drastic  measures  attention  should  be  given  to  the  local 
lesion  and  the  surrounding  tissues  should  be  fully  injected  with  the  antitoxin. 
The  entire  process  described  above  may  be  repeated  daily  until  there  is 
subsidence  of  the  symptoms.  Anaesthesia  is  of  course  necessary  in  this  treat- 
ment. Subdural  injections  of  antitoxin  by  means  of  trephining  have  been 
practised  but  these  would  seem  in  no  way  superior  to  the  less  difficult  injec- 
tions into  the  tissues,  veins,  nerves  and  cord. 

Excellent  results  have  been  reported  from  the  employment  of  subcutaneous 
injections  of  an  emulsion  of  rabbit's  brain,  the  basis  of  the  treatment  being 
the  fact  that  the  tendency  of  tetanus  toxin  is  to  become  incorporated  and 
fixed  in  the  nerve  structures. 

At  least  one  patient  has  been  cured,  after  the  antitoxin  treatment  had 
seemed  to  fail,  by  the  removal  of  cerebrospinal  fluid  by  means  of  lumbar  punc- 
ture and  injecting  into  the  subarachnoid  space  45  minims  (3.0)  of  a  solution 
containing  i^  grains  (o.i)  of  eucaine,  |  of  a  grain  (0.022)  of  morphine  and 
three  grains  (0.2)  of  sodium  chloride.  An  amelioration  was  immediately  noted 
and  the  process  was  repeated  several  times,  the  patient  ultimately  recovering. 

Very  recently  treatment  by  means  of  the  injection  of  a  solution  of  magne- 
sium sulphate  into  the  spinal  canal  by  means  of  lumbar  puncture  has  been  sug- 
gested and  the  few  results  so  far  reported  seem  to  justify  the  method;  25  and 
12 J  percent,  solutions  have  been  employed,  the  amount  injected  being  about 
15  minims  (i.o)  for  every  25  pounds  of  the  patient's  weight.  Repeated  injec- 
tions may  be  given  and  the  treatment  is  said  to  restrain  the  convulsions  and 
relieve  the  pain,  thus  preserving  the  patient's  strength  and  preventing  exces- 
sive metabolism  and  heat  production;  the  spasm  of  the  muscles  of  the  jaw 
is  lessened,  thereby  permitting  the  administration  of  food  by  mouth.  The 
action  of  the  salt  is  continued  for  a  considerable  period  without  depressing 
the  heart  and  no  ill-effects  are  likely  to  be  produced  save  an  inhibition  of  the 
action  of  the  bladder,  rendering  catheterization  necessary.  It  is  possible 
that  the  drug  exerts  some  chemical  action  upon  the  toxins  of  the  disease 


ANTHRAX.  131 

but  more  probably  its  effect  is  purely  symptomatic.  This  form  of  treat- 
ment may  be  employed  to  advantage  in  connection  with  that  by  means  of 
tetanus  antitoxin. 

Treatment  by  means  of  the  repeated  hypodermatic  injection  of  two  percent, 
phenol  is  said  to  act  favorably  upon  the  nervous  system  and,  to  a  certain 
extent,  to  neutralize  the  effect  of  the  toxin  of  the  disease. 

Amputation  of  the  wounded  limb  has  its  advocates. 

With  regard  to  the  treatment  of  the  paroxysms  it  may  be  said  that  they 
are  best  controlled  by  chloroform  inhalations  but  they  may  be  avoided,  or  at 
least  decreased  in  intensity,  by  the  use  of  various  hypnotics.  Of  these  mor- 
phine given  hypodermatically  is  the  most  efficient  and  the  patient  may  be  kept 
under  its  influence.  Hydrated  chloral  given  together  with  the  bromides  may 
prove  effective;  physostigma — I  to  J  a  grain  (0.0165  to  0.033) — given  every 
three  to  six  hours  and  curare — ^t  o^  ^  grain  (0.0026) — administered  hypoder- 
matically, the  dose  being  gradually  but  with  caution  increased,  may  benefit 
the  condition. 

The  resulting  stiffness  frequently  observed  during  convalescence  may  be 
markedly  relieved  by  the  tincture  of  conium  in  doses  gradually  increased 
until  the  physiological  effects  are  noted. 

Stimulation  is  necessary  when  the  heart  and  circulation  become  depressed 
and  warm  baths  may  aid  in  relaxing  the  spastic  condition  and  are  grateful 
to  the  sufferer. 

The  nourishment  should  be  maintained  at  the  highest  possible  level  since 
it  is  said  that  tetanus  antitoxin  does  not  exert  its  best  influence  in  conditions 
of  impoverished  nutrition.  The  diet,  however,  must  of  necessity  be  chiefly 
of  fluids  and  feeding  by  the  nasal  tube  or  per  rectum  becomes  imperative 
when  deglutition  becomes  diflacult  or  impossible. 

ANTHRAX. 

Synonyms.  Malignant  Pustule;  Wool  Sorter's  Disease;  Splenic  Fever; 
Splenic  Apoplexy. 

Definition.  An  infectious  disease  of  animals,  particularly  cattle  and  sheep 
and  transmissible  to  man. 

^Etiology.  This  disease  in  animals  is  widespread  but  is  less  common  in 
America  than  in  Europe  and  Asia.  In  man  it  occurs  as  a  result  of  infection 
through  the  skin,  lungs  or  digestive  tract  and  is  most  often  seen  in  those  who 
work  about  animals  or  animal  products,  such  as  shepherds,  hostlers,  tanners, 
butchers,  etc.  The  contagium  is  transferred  to  man  by  means  of  the  hides, 
flesh,  blood  and  secretions  of  affected  animals  and,  while  the  possibility  of 
contracting  the  infection  through  an  intact  skin  or  mucous  membrane  is 
to  be  considered,  it  is  probable  that  a  solution  of  continuity  of  the  integu- 
ment is  necessary  for  a  successful  inoculation. 


132  THE    INFECTIOUS    DISEASES. 

The  specific  cause  of  anthrax  is  a  cylindrical  bacillus  of  great  vitality  and 
the  argest  of  the  pathogenic  bacteria.  It  is  termed  the  bacillus  anthracis 
and  exists  in  great  numbers  in  the  blood  and  tissues  of  the  infected  subject. 
While  the  bacilli  themselves  may  be  easily  destroyed,  their  spores  are  very 
resistant  to  disinfecting  agents.  Animals  acquire  the  disease  through  abra- 
sions such  as  insect  bites,  etc.,  by  feeding  upon  the  flesh  of  other  animals  dead 
from  the  infection  and  by  grazing  over  fields  where  the  bacilli  are  present, 
for  these  have  been  found  upon  the  herbage  over  the  buried  bodies  of  animals 
which  have  died  of  anthrax. 

Symptoms.  The  incubation  of  anthrax  is  usually  about  one  week  and 
for  convenience  in  description  the  disease  may  be  considered  as  occurring  in 
two  forms,  the  external  and  the  internal. 

External  Anthrax,  a.  Malignant  pustule  occurs  as  a  result  of  inocu- 
lation and  most  often  begins  upon  the  exposed  surfaces  of  the  face,  hands 
or  arms.  The  first  symptom  is  pain,  itching  or  biurning  in  character,  at  the 
site  of  inoculation.  Soon  a  reddened  spot  appears  which  quickly  becomes 
papular  and  then  vesicular,  the  vesicle  containing  clear  or  bloody  serum. 
The  surrounding  tissues  become  indurated  and,  the  original  vesicle  bursting, 
other  vesicles  develop  about  the  indurated  area.  The  induration  extends 
and  becomes  darkened  at  its  center,  a  brown  eschar  usually  appearing  within 
36  hours.  The  neighboring  tissues  are  oedematous  and,  the  infection  spreading 
along  the  lymphatic  channels,  these  become  reddened,  swollen  and  tender 
and  the  adjacent  lymph  ganglia  are  enlarged. 

There  is  accompanying  constitutional  disturbance,  the  temperature  and  pulse 
rate  being  elevated  and  other  symptoms  of  an  acute  infection  being  present. 
Later  the  temperature  may  fall  below  normal  and  in  fatal  instances  death 
supervenes  after  from  three  to  five  days.  In  favorable  instances  with  mild 
constitutional  symptoms  the  vesicles  may  scab  and  with  the  induration  gradu- 
ally disappear  or  the  eschar  may  slough  away  leaving  the  wound  to  heal. 

h.  Malignant  anthrax  oedema  usually  begins  in  the  eyelid,  spreading  thence  to 
the  face;  it  also  may  occur  in  the  hands  or  arms;  papules  and  vesicles  do  not 
appear  but  there  is  marked  oedema  which  may  go  on  to  gangrene.  The 
constitutional  symptoms  may  precede  the  local  manifestations  and  are  usually 
of  severe  tj-pe.     Recoverv  from -this  form  of  the  disease  is  practically  unknown. 

A  marked  characteristic  of  both  forms  of  the  infection  is  the  absence  of 
mental  anxiety,  the  mind  often  remaining  wholly  unaffected. 

Internal  anthrax  also  occurs  in  two  forms,  a.  Intestinal  anthrax  or 
mycosis  intestinalis  results  from  the  ingestion  of  the  meat  or  milk  of  infected 
animals  or  from  the  transference  of  the  contagium  of  external  anthrax  to  the 
digestive  tract.  There  is  likely  to  be  a  chill  at  the  onset  which  is  succeeded 
by  the  symptoms  of  intense  intoxication,  such  as  vomiting,  diarrhoea  with 
bloody  stools,  general  pains,  fever  and  abdominal  tenderness.     In  the  severe 


ANTHRAX.  133 

infections  the  respiration  is  difl&cult,  cyanosis  and  pronounced  mental  symp- 
toms are  present  and  there  may  be  extravasations  of  blood  from  the  mucous 
membranes  or  petechial  haemorrhages  into  the  skin.  There  is  splenic  en- 
largement, the  blood  is  dark,  remains  uncoagulated  for  a  considerable  period 
post  mortem  and,  in  the  later  stages  of  the  disease,  may  contain  the  bacillus 
anthracis.     Convulsions  may  be  observed  shortly  before  death. 

b.  Wool  sorter's  disease  is  seen  amongst  those  who  work  in  wool  or  hides, 
especially  those  imported  from  South  America  or  Russia,  and  is  the  result 
of  the  inhalation  or  of  swallowing  the  contagium.  There  is  seldom  an 
external  lesion  and  the  onset  of  the  infection  is  usually  abrupt  with  a  chill, 
high  temperature,  general  pains  and  prostration.  The  heart  action  is  rapid 
and  feeble  and  there  is  dyspnoea  and  thoracic  pain.  Cough  with  accompanying 
physical  signs  of  bronchitis  is  not  infrequent.  Death  may  occur  in  collapse 
within  24  hours  or  the  disease  may  be  prolonged  with  vomiting,  diarrhoea 
and  cerebral  symptoms.  In  such  infections  the  capillaries  of  the  brain  have 
been  found  to  contain  the  bacillus  anthracis  in  great  numbers. 

Rag  picker's  disease  is  the  name  given  to  a  pulmonary  and  pleural  anthrax 
infection  which  is  accompanied  by  a  general  intoxication. 

The  diagnosis  of  anthrax  of  the  external  form  may  be  made  from  the  local 
appearances  and  from  the  history.  Bacteriological  examination  of  the  con- 
tents of  the  vesicle  may  reveal  the  presence  of  the  specific  micro-organism. 
Inoculation  experiments  are  also  useful.  Internal  anthrax  is  less  simple 
of  diagnosis  but  may  be  suggested  by  a  history  of  exposure. 

The  prognosis  is  distinctly  bad,  particularly  in  the  internal  types. 

Treatment.  Much  may  be  done  in  the  way  of  prevention  by  the  disin- 
fection of  hides,  wool,  rags,  etc.,  by  means  of  steam  under  pressure.  Hides, 
unfortunately,  are  damaged  by  this  process.  All  animals  dead  from  the 
disease  should  be  burned,  not  buried,  grazing  over  infected  pastures  should 
be  prohibited  and  the  thorough  disinfection  of  infected  buildings  is  of  much 
importance. 

The  site  of  the  lesion  in  external  anthrax  should  be  excised  if  possible  or,  if 
not,  deep  crucial  incisions  are  to  be  made  and  followed  by  cauterization  with 
the  thermo-cautery,  phenol  or  a  solution  of  potassium  hydrate.  The  wound 
should  then  be  dressed  with  a  strong  solution  of  phenol  or  powdered  with 
pure  mercury  bichloride.  General  or  local  anesthesia  may  be  necessary. 
Injections  beneath  the  skin  of  the  surrounding  parts  may  be  efifectual  in 
preventing  the  spread  of  the  infection.  Such  solutions  as  ^  percent,  phenol; 
2  to  5  percent,  tincture  of  iodine;  iodine  one  part,  potassium  iodide 
two  parts,  water  one  thousand  parts,  may  be  injected  several  times  daily. 
Mercury  bichloride  is  also  useful  in  this  connection.  The  technique  of  such 
injections  is  as  follows:  At  a  distance  of  about  |  an  inch  from  the  margin 
of  the  indiurated  area  the  needle  is  inserted  and  the  injection  made;  other 


134  THE    INFECTIOUS    DISEASES. 

injections  are  given  outside  the  periphery  of  the  inflammation  at  such  intervals 
that  the  tissue  infikrated  with  the  chosen  solution  shall  act  as  a  continuous 
barrier  to  the  progress  of  the  infection.  The  injection  of  the  solution  of 
iodine  and  potassium  into  the  enlarged  lymph  glands  is  also  advised. 

Internally  we  may  give  lo  to  30  drops  (0.66  to  2.0)  of  tincture  of  iodine 
daily  or  ^  an  ounce  (15.0)  every  two  hours  of  the  mixture  of  iodine  and  potas- 
sium iodide  mentioned  above.  Stimulants  such  as  alcohol  and  strychnine 
should  be  prescribed  as  indications  arise  and  the  dietary  should  be  as  plentiful, 
nutritious  and  as  digestible  as  possible. 

Internal  anthrax  is  likely  to  be  little  influenced  by  treatment.  The  bowels 
should  be  freely  moved  at  the  onset  and  kept  open  during  the  course  of  the 
disease  in  order  that,  if  possible,  the  toxic  matters  may  be  removed;  the  treat- 
ment described  above  may  be  employed  and  the  free  exhibition  of  intestinal 
antiseptics  is  advocated. 

An  antiserum  for  the  treatment  of  anthrax  has  been  elaborated  and  from 
the  results  claimed  would  seem  to  merit  a  trial. 

GLANDERS. 

Synonyms.     Farcy;  Malleus  Humidus. 

Definition.  An  infectious  disease  particularly  of  the  horse  but  com- 
municable to  other  animals  such  as  the  sheep,  rabbit,  cat,  dog  and  mouse; 
cows  enjoy  immunity.  The  disease  is  manifested  by  nodular  growths  in  the 
nostrils  (glanders)  and  under  the  skin  (farcy). 

iEtiology.  The  disease  is  rare  in  man  but  may  be  seen  in  stablemen 
and  others  who  work  about  horses.  Its  specific  cause  is  a  micro-organism, 
the  bacillus  mallei.  The  infection  is  transferred  to  man  by  inoculation 
through  an  abrasion  of  the  skin  or  through  a  mucous  membrane,  the  conta- 
gium  being  given  off  in  the  discharges  from  the  diseased  animal. 

Pathology.  The  characteristic  lesion  of  glanders  is  the  appearance  of 
granulomatous  tumors  of  varying  size,  composed  of  epithelial  and  lymphoid 
cells  and  containing  the  hacillus  mallei.  These  tumors  occur  beneath  the 
skin  and  on  the  mucous  membranes  where  they  soon  break  down  forming 
respectively  abscesses  and  ulcerations.  The  nodules  have  also  been  observed 
in  the  viscera  and  in  the  nervous  and  osseous  systems. 

Symptoms.  Acute  and  chronic  forms  of  both  glanders  and  farcy  occur 
in  man. 

The  incubation  period  of  acute  glanders  is  from  three  to  five  days.  The 
onset  is  characterized  by  the  usual  symptoms  of  beginning  febrile  disease; 
at  the  site  of  the  infection  there  are  redness  and  swelling,  the  nasal  mucous 
membrane  in  the  vicinity  becomes  first  dry  and  congested,  the  appearance 
of  the  nodular  tumors  rapidly  follows,  and  these  soon  break  down  becoming 
ulcers  which  discharge  a  muco-purulent  or  bloody  secretion.     The  infection 


GLANDERS.  1 35 

may  cause  severe  frontal  headache  due  to  accompanying  involvement  of  the 
sinuses  in  this  neighborhood.  The  submaxillary  and  cervical  lymph  glands 
become  enlarged  and  may  suppurate  and  the  inflammatory  process  spreads 
to  the  nasal  septum,  to  the  mouth,  pharynx  and  even  to  the  lower  air  passages, 
causing  pain  on  swallowing,  cough  with  foul  expectoration,  and  even  pneu- 
monia. A  papular  eruption,  which  soon  becomes  pustulous  and  may  be 
mistaken  for  smallpox,  may  appear  upon  the  face  and  upon  the  skin  over  the 
articulations. 

Chronic  glanders  is  difficult  of  diagnosis.  Its  symptoms  resemble  those 
of  a  chronic  rhinitis  or  laryngitis  for  either  of  which  it  is  likely  to  be  mistaken. 
There  are  ulcerations  of  the  nasal  mucous  membrane.  The  diagnosis  may 
be  made  by  inoculating  the  peritonaeum  of  a  guinea  pig  with  the  nasal  secre- 
tion or  with  a  culture  grown  from  this  substance.  If  glanders  is  present 
the  testicles  of  the  animal  become  swollen  and  inflamed  within  a  few  days 
and  ultimately  suppurate.  The  guinea  pig  dies  within  three  or  four  weeks 
and  nodules  are  found  in  the  abdominal  organs. 

Aaite  farcy  is  evidenced  by  the  symptoms  of  an  acute  infection  accom- 
panied by  a  subcutaneous  nodule  or  an  ulcer  with  a  foul  secretion.  The 
neighboring  parts  become  congested  and  oedematous  and  adjacent  lymphat- 
ics are  involved;  "farcy  buds,"  which  are  subcutaneous  nodules  along  the 
course  of  the  lymph  vessels,  develop  and  may  suppurate.  Intra-muscular 
abscesses  and  articular  swellings  may  appear  and  rarely  a  pustular  rash 
occurs.  The  nose  is  not  affected  and  the  urine  may  contain  the  bacillus 
mallei. 

Chronic  farcy  is  characterized  by  localized  subcutaneous  nodules,  usually 
occurring  upon  the  extremities;  their  development  is  sluggish  and  while 
they  break  down,  forming  abscesses  or  ulcers,  there  is  no  marked  lymphatic 
involvement.  The  course  is  protracted  and  pyaemic  symptoms  or  acute 
glanders  may  develop. 

The  diagnosis  in  acute  glanders  is  seldom  difficult  but  in  the  chronic  form 
is  less  simple.  Recently  the  agglutination  test  has  been  employed  since  it 
has  been  proven  that  while  normal  horse  serum  agglutinates  glanders  bacilli 
in  a  dilution  of  i  to  200,  that  of  a  horse  affected  with  glanders  will  agglutinate 
a  I  to  1,000  dilution.  Mallein,  a  product  of  the  growth  of  the  glanders  bacillus 
analogous  to  the  tuberculin  of  tuberculosis,  may  be  employed  in  diagnosis. 
Inoculation  with  this  substance  causes  a  rise  of  temperature  when  glanders 
is  present,  a  rise  in  horses  of  3.5°  F.  (2°  C.)  being  considered  proof  that  the 
animal  is  diseased,  while  an  elevation  of  1.25°  F.  (0.75°  C.)  is  considered  sus- 
picious. Direct  animal  inoculation  will  quickly  determine  the  presence 
or  absence  of  the  infection  and  implantation  of  cultures  from  the  secretion 
upon  cooked  potatoes  shows  within  three  or  four  days  an  amber  colored 
film,  becoming  by  the  end  of  a  week  red  and  encircled  by  a  pale  green  area. 


136  THE    IXFECTIOUS    DISEASES. 

The  prognosis  in  the  acute  forms  is  almost  invariably  fatal.  In  the  chronic 
types  about  half  the  patients  recover. 

Treatment  consists  in  the  early  excision  and  cauterization  of  the  lesion; 
antiseptic  dressings  should  then  be  applied.  In  the  nasal  form  of  the  infec- 
tion antiseptic  sprays  and  gargles  of  dilute  phenol  or  hydrogen  dioxide  arc 
to  be  employed.  Farcy  buds  should  be  incised  and  dressed  antisepticall}'. 
Mallein  has  been  employed  in  animals  and  has  been  administered  internally 
to  human  beings  with  no  very  positive  results.  The  patient's  nutrition  should 
be  kept  up  by  a  supporting  diet,  symptoms  should  be  combated  as  they  arise 
and  stimulation  is  to  be  prescribed  when  indicated. 

ACTINOMYCOSIS. 

Synonyms.     Lumpy  Jaw;  Big  Jaw;  Bone  Tumor;  Swelled  Head. 

Definition.  A  chronic  infectious  inflammatory  disease  of  cattle  and  pigs, 
transmissible  to  man  and  caused  by  the  streptothrix  actinomyces  or  ray  fungus. 

iiEtiology.  The  disease  is  common  in  cattle,  is  more  frequently  seen  in 
man  in  Germany  than  in  England  or  America  and  affects  males  more  fre- 
quently than  females.  The  fungus  probably  reaches  the  human  organism 
upon  the  ingested  food.  Direct  infection  with  meat  or  milk  has,  however, 
never  been  proven.  It  has  been  shown  that  the  disease  may  be  conveyed 
to  cattle  upon  oats  and  other  grains  and  it  is  not  improbable  that  man  may 
contract  the  disease  in  the  same  manner.  The  infection  takes  place  usually 
through  the  mouth,  teeth  or  throat,  rarely  through  the  skin  or  respiratory 
passages. 

Pathology.  The  characteristic  lesion  is  a  miliary  nodule,  made  up  cf 
a  central  mass  of  fungi  radiating  in  all  directions  and  surrounded  by  granula- 
tion tissue.  The  size  of  a  single  nodule  is  about  that  of  a  millet  seed  but 
numbers  of  these  may  be  aggregated  into  tumors  the  size  of  a  base-ball; 
about  the  larger  tumors  the  connective  tissue  is  greatly  proliferated  and  finally 
suppuration  with  abscess  formation  takes  place. 

Symptoms,  a.  The  digestive  tract.  The  infection  usually  takes  place 
through  the  mouth  or  decayed  teeth,  the  jaw  becomes  swollen  and  the  face  so 
enlarged  that  the  condition  may  be  mistaken  for  sarcoma;  sinuses  discharging 
pus  are  often  present.  Rarely  the  tongue,  pharynx,  intestines  or  liver  may  be 
involved  primarily,  or  secondarily  as  a  result  of  metastasis.  Actinomycotic 
appendicitis  has  been  observed  and  the  fungi  have  been  demonstrated  in  the 
stools. 

b.  Pulmonary  actinomycosis.  Infection  of  the  lungs  by  the  ray  fungus 
is  not  infrequent  and  occurs  in  three  types.  First,  a  form  with  lesions  resem- 
iDhng  those  of  chronic  bronchitis,  the  sputum  containing  the  fungi.  Second,  a 
miliary  form  in  which  tubercles  occur  resembling  those  due  to  the  bacillus 


BLASTOMYCOSIS.  I37 

of  Koch  but  in  which  the  actinomyces  are  demonstrable.  Third,  a  destructive 
form  characterized  by  interstitial  lesions  and  abscesses  which  may  form 
cavities.  The  pulmonary  type  of  the  disease  may  occur  synchronously 
with  involvement  of  the  jaw  or  other  parts.  The  cough  is  accompanied  by 
a  foetid  sputum,  in  which  the  actinomyces  may  be  demonstrated,  and  fever, 
which  is  usually  septic  in  character  if  suppuration  has  taken  place.  The 
course  of  the  infection  is  protracted,  the  average  duration  being  about  10 
months;  recovery  is  rare. 

c.  Actinomycosis  of  the  skin  is  a  chronic  condition  characterized  by  the 
development  of  cutaneous  swellings  which  break  down  and  result  in  ulcers 
in  the  discharge  of  which  the  fungi  have  been  found. 

d.  Cerebral  actinomycosis  is  a  very  rare  type  of  the  disease.  It  is  charac- 
terized by  the  formation  of  abscesses  in  the  brain,  the  pus  of  which  may  con- 
tain the  mycelium. 

The  diagnosis  can  be  assured  only  upon  demonstrating  the  fungi  in  the  pus 
or  other  discharges  from  the  lesions;  unless  this  can  be  done  the  condition 
is  likely  to  be  confounded  with  pyaemia,  which,  in  actuality,  it  is. 

Actinomycosis  of  the  jaw  may  be  differentiated  from  sarcoma  by  its  more 
protracted  course,  greater  tendency  to  suppuration  and  the  presence  of  actin- 
omyces. 

Treatment  in  general  consists  in  the  administration  of  potassium  iodide 
in  doses  of  from  30  to  75  grains  (2.0  to  5.0)  daily,  gradually  increased  to  go 
to  120  grains  (6.0  to  8.0)  and  the  maintenance  of  the  patient's  strength  by 
nourishing  food,  arsenic  and  other  tonics.  In  pulmonary  actinomycosis, 
in  addition  to  the  internal  administration  of  potassium  iodide,  antiseptic 
inhalations  should  be  employed  as  in  foetid  bronchitis  (see  p.  636)  and  the 
vapor  of  iodine  is  particularly  effectual.  The  internal  measures  applicable 
in  the  foetid  form  of  bronchitis  are  also  useful  and  especially  the  preparations 
of  eucalyptus.  Actinomycosis  of  the  intestine  necessitates  attempts  at 
achieving  intestinal  antisepsis. 

If  the  tumor  is  so  situated  as  to  allow  of  excision  this  should  be  performed 
and  the  dead  bone  and  infected  tissues  removed,  the  wound  and  sinuses  drained 
and  irrigated  with  a  solution  of  iodine  and  potassium  iodide  or  of  iodoform 
and  glycerin.  Cauterization  of  the  infected  tissues  with  zinc  chloride  is 
also  recommended.  Intestinal  actinomycosis  with  localized  pus  foci  neces- 
sitates laparotomy  and,  in  the  cerebral  type,  if  the  symptoms  suggest  a  localized 
abscess,  surgical  interference  is  also  indicated. 

BLASTOMYCOSIS. 

Definition.  A  chronic  inflammatory  disease  characterized  by  various 
lesions,  particularly  of  the  skin,  and  due  to  infection  with  a  fungus  of  the 
yeast  variety  termed  hlastomycetes. 


138  THE    INFECTIOUS    DISEASES. 

Etiology.  As  stated  above  this  affection  is  the  result  of  the  action  of  the 
specific  fungus,  which  is  a  rounded,  ovoid  or  irregularly  shaped  body  possess- 
ing a  homogeneous  capsule  and  made  up  of  finely  or  coarsely  granular  pro- 
toplasm which  sometimes  contains  a  clear  vacuole  of  varying  size.  The 
fungi  may  be  obtained  from  the  diseased  tissues  and  from  the  pus  of  the  blas- 
tomycetic  abscess.  Organisms  from  different  patients  often  differ  in  their 
cultural  behavior,  consequently  it  is  very  possible  that  this  type  of  fungus 
may  later  be  differentiated  into  separate  classes. 

Among  the  first  blastomycetic  infections  to  be  observed  were  those  affecting 
the  skin;  here  previous  traumatism  seems,  in  some  instances,  to  have  been 
a  predisposing  factor  in  the  aetiology.  Involvement  of  the  various  viscera 
has  followed  the  skin  infections  in  some  instances,  while  in  others  the  organ- 
ism seems  to  have  effected  its  first  entry  by  means  of  the  lungs.  In  the  skin 
infections,  the  lesions  being  in  the  form  of  subcutaneous  miliary  abscesses, 
it  is  easy  to  account  for  the  subsequent  visceral  involvement,  for  here  the 
infection  probably  is  carried  by  means  of  the  blood  or  the  lymph  circulation. 
Primary  pulmonary  infection  doubtless  follows  the  inhalation  of  the  fungus, 
and  its  lodgment  and  subsequent  development  in  the  bronchial  tract  ensues. 

Pathology.  The  skin  in  this  affection  exhibits  lesions  similar  to  those 
of  tuberculosis  verrucosa  cutis;  there  are  purplish  elevated  areas  which  are 
soft  and  spongy  and  from  the  bases  of  which  drops  of  pus  may  be  expressed; 
there  may  also  be  small  raised  nodules  not  larger  than  a  pea  and  reddish 
in  color.  Microscopic  sections  show  epithelial  hyperplasia,  tiny  intra-epithe- 
lial  abscesses,  a  granulomatous  condition  of  the  corium,  and  the  presence 
of  the  specific  fungus. 

The  lung  of  pulmonary  blastomycosis  is  characterized  by  a  surface  studded 
with  grayish-white  or  yellow  nodules;  these  are  firm  in  texture,  are  slightly 
elevated  and  resemble  miliary  tubercles.  Both  lungs  are  usually  involved 
but  often  not  to  an  equal  extent.  There  may  be  pleuritic  adhesions.  Sec- 
tion of  the  lung  shows  a  fairly  uniform  distribution  of  the  nodules  through- 
out the  pulmonary  tissue;  a  tendency  to  the  formation  of  clusters  is  not  un- 
usual. The  lung  structure  between  the  nodules  appears  normal.  The 
miliary  bodies  are  yellowish  at  their  centers  and  upon  being  squeezed  exude  a 
small  amount  of  pus;  they  are  situated  in  the  connective  tissue  surrounding 
the  bronchi  and  the  blood-vessels. 

Symptoms.  These  vary  with  the  situation  and  number  of  the  lesions  but, 
since  in  all  reported  instances  of  generalized  blastomycosis  the  pulmonary 
manifestations  have  been  most  prominent,  the  symptomatology  is  chiefly 
referable  to  the  lungs.  Cough  is  constant  but  variant  in  intensity  and  fre- 
quency; rarely  it  may  be  so  slight  as  to  attract  no  attention.  Expectoration  is 
usually  present.  It  may  be  purulent,  muco-purulent  or  blood  stained;  the 
blood  probably  results  from  the  severity  of  the  effort  of  coughing,  for  there  is 


EPIDEMIC    STOMATITIS.  I39 

no  tendency  to  the  development  of  cavities.  Fungi  may  be  demonstrated 
in  the  sputum.  Dyspnoea  may  be  present,  differing  in  degree  with  the  ex- 
tent of  the  lesions;  the  respiration  and  pulse  are  usually  accelerated.  There 
is  generally  a  rather  constant  elevation  of  temperature,  dependent,  as  in  tu- 
berculosis, upon  the  presence  of  septic  bacteria  and  upon  the  absorption  of 
their  products.  Temperature  of  py^emic  type  has  been  observed.  Chilly 
feelings  and  sweating  occur  when  there  is  a  mixed  infection. 

Physical  Signs.  These  are  in  no  way  characteristic,  but  dulness  and  bron- 
chial breathing  over  the  lesions  are  usually  present. 

The  diagnosis  depends  upon  the  demonstration  of  the  specific  fungi  in 
the  sputum  and  upon  the  presence  of  the  typical  skin  lesions. 

The  prognosis.  The  disease  may  last  for  months  or  years  but  is  probably 
ultimately  fatal  in  all  instances. 

Treatment.  The  nursing,  diet  and  general  hygiene  of  the  patient  should 
be  conducted  upon  the  same  lines  as  those  applicable  in  pulmonary  tubercu- 
losis, and  the  sputum  should  be  properly  disinfected.  Just  as  in  pulmonary 
actinomycosis  the  drug  which  is  our  chief  stay  is  potassium  iodide;  large  doses 
should  be  employed,  the  usual  amount  being  from  one  drachm  (4.0)  to  one 
and  a  half  drachms  (6.0)  daily.  The  iodine  is  said  to  cause  a  destruction 
of  the  tissues  about  the  fungus  in  actinomycotic  growths  with  the  result  that 
the  organism  may  be  discharged  if  a  clear  exit  is  provided  and  it  is  possible 
that  a  similar  process  may  take  place  in  blastomycetic  infections.  The  em- 
ployment of  X-ray  exposures  is  said  to  increase  the  absorption  of  the  iodine, 
consequently  the  ray  may  be  employed  in  connection  with  the  administration 
of  the  iodide.  Exposures  have  been  made  as  frequently  as  every  two  days, 
but  in  the  present  status  of  our  knowledge  of  the  possible  evil  effects  of  this 
form  of  treatment  it  should  be  given  by  none  but  those  who  are  expert  in  its 
manipulation  and  even  then  with  great  care. 

The  inhalation  of  the  vapor  of  copper  sulphate  solution  from  a  nebulizer 
or  in  the  form  of  steam  has  been  suggested  on  account  of  the  destructive 
action  that  this  substance  is  known  to  possess  over  certain  vegetable  growths, 
notably  algae.  The  spray  should  not  be  so  strong  as  to  irritate  the  linings  of 
the  respiratory  tract,  but  it  should  be  used  as  continuously  as  possible. 

Subcutaneous  abscesses  should  be  incised  and  drained ;  if  extensive  lesions 
are  demonstrated  in  the  lungs  these  also  may  be  treated  surgically;  the  wounds 
should  be  allowed  to  remain  open,  in  order  to  allow  free  exit  to  the  infectious 
matter  which  may  be  assisted  by  the  administration  of  potassium  iodide. 

EPIDEMIC  STOMATITIS. 

Synonyms.  Foot  and  Mouth  Disease;  Aphthous  Fever;  Aphthae  Epizo- 
otics. 

Definition.     An  acute  infectious  disease  of  animals  most  frequently  seen 


I40  THE    INFECTIOUS    DISEASES. 

in  cattle,  sheep,  and  pigs,  occurring  rarely  in  dogs,  cats  and  fowls,  and  char- 
acterized by  the  presence  of  vesicles  and  ulcers  upon  the  buccal  mucous 
membrane,  in  the  clefts  about  the  feet  and  upon  the  udders.  It  may  occur 
in  epidemics,  when  it  spreads  with  great  rapidity  and  may  entail  consider- 
able loss  to  the  grazing  interests.     The  infection  is  transmissible  to  man. 

iEtiology.  The  disease  occurs  in  human  beings  as  a  result  of  drinking 
the  milk  or,  more  rarely,  of  eating  cheese  or  butter  from  infected  cattle,  and 
through  contact  with  the  contents  of  the  vesicles  in  the  mouths  or  upon  the 
teats  of  the  diseased  animal.  Meat  from  such  animals  does  not  appear  to  be 
infective.  No  micro-organism  has  yet  been  demonstrated  to  be  responsible 
for  this  disease  and,  while  it  may  be  of  microbic  origin,  the  specific  cause  is 
probably  too  small  to  be  visible  through  the  microscope  since  the  contents 
of  the  vesicles  retains  its  infective  properties  after  passage  through  a  porcelain 
filter  which  is  impermeable  to  the  most  minute  bacteria.  Animals  may  be 
rendered  immune  by  a  vaccine  elaborated  by  Loffler. 

Infants  may  be  infected  by  milk  from  diseased  cows  and  a  connection  has 
been  suggested  between  the  aphthous  stomatitis  of  children  and  foot  and 
mouth  disease. 

Symptoms.  After  an  incubation  period  of  from  three  to  five  days  the  onset 
is  marked  by  a  rise  in  temperature,  malaise,  anorexia  and  digestive  distur- 
bance; these  may  be  preceded  by  a  chill  or  chilly  sensations.  Vesicles  con- 
taining a  yellow  serum  appear  upon  lips,  tongue  and  pharynx;  the  mouth 
is  hot,  its  lining  is  red  and  swollen  and  there  may  be  interference  with  speech 
and  deglutition;  the  saliva  is  increased.  An  eruption  of  vesicles,  which  may 
become  pustules,  appears  upon  the  skin  particularly  of  the  fingers  and  toes, 
about  the  nipples  in  women  and  at  times  over  other  parts  of  the  body.  This 
rash  may  be  mistaken  for  that  of  smallpox  or  for  vaccinia  if  it  occurs  after 
vaccination.     The  vesicles  within  the  mouth  may  go  on  to  ulceration. 

The  prognosis  is  good  except  in  young  infants. 

Treatment.  Prevention  consists  in  boiling  all  suspected  milk  and  insis- 
tence upon  cleanliness  in  the  care  of  animals. 

The  diseased  mucous  membrane  should  be  kept  clean  by  means  of  simple 
antiseptic  mouth  washes  of  potassium  chlorate,  boric  acid  or  liquor  antisepticus. 
The  ulcers  should  be  powdered  with  burnt  alum  or,  if  this  is  inefficient,  touched 
with  stick  silver  nitrate.  The  cutaneous  eruption  necessitates  the  employ- 
ment of  mild  lotions  of  i  to  5  or  10,000  mercury  bichloride  solution  and  of 
dressings  of  sterile  gauze.  In  other  regards  the  treatment  is  wholly  symp- 
tomatic. 

MILK  SICKNESS. 

Synonyms.     The  Trembles;  The  Slows. 

Definition.      An  acute  infectious  disease  of  man  and  the  lower  animals 


GONORRHCEAL    INFECTIONS.  14I 

formerly  common  in  the  Western  states  and  at  present  sometimes  seen  in  North 
Carolina,  Ohio,  Indiana,  Kentucky,  West  Virginia  and  Michigan.  In  animals 
it  is  termed  "the  trembles." 

.etiology.  The  disease  is  most  frequently  observed  in  newly  settled 
lands  and  seems  to  disappear  as  the  ground  is  cultivated  and  the  forests  are 
cleared.  Its  specific  cause  is  not  known  but  the  infection  is  probably  trans- 
mitted to  man  through  the  milk,  cheese  and  butter,  as  well  as  by  the  means  of 
the  flesh,  of  diseased  animals.  The  contagium  may  have  its  origin  in  the 
soil  and  a  spirillum  has  been  found  in  the  blood  of  sufferers,  but  this  as  yet 
has  not  been  proven  to  be  a  distinct  aetiologic  factor. 

Pathology.  No  characteristic  morbid  changes  have  been  described, 
few  autopsies  upon  human  beings  having  been  performed. 

Symptoms.  After  an  indefinite  incubation  period  and  prodromal  symp- 
toms lasting  a  few  days  and  consisting  of  increasing  malaise,  headache  and 
loss  of  appetite,  the  onset  of  the  disease  occurs.  This  is  sudden  and  marked 
by  nausea  and  regurgitant,  never  foecal,  vomiting,  gastric  pain,  obstinate,  some- 
times absolute  constipation,  thirst  and  moderate  rise  of  temperature.  The 
mouth  is  dry,  the  tongue  tremulous  and  swollen  and  the  breath  is  foul  and  it  and 
the  patient  possess  a  characteristic  odor.  The  pulse  is  at  first  full  and  rapid, 
later  the  typhoid  state  may  supervene,  when  it  becomes  small  and  weak,  and 
pronounced  cerebral  symptoms  appear.  Convulsions  may  be  noted.  The 
severer  and  more  acute  infections  may  terminate  fatally  within  a  few  days, 
in  other  instances  the  disease  may  be  protracted  for  three  or  four  weeks. 

The  diagnosis  is  usually  made  by  exclusion  and  upon  the  fact  that  "the 
trembles"  is  prevalent  among  the  cattle  of  the  neighborhood. 

The  prognosis  is  unfavorable,  the  disease  generally  proving  fatal. 

Treatment.  Prevention  consists  in  the  avoidance  of  all  possibly  infected 
milk,  meat  or  other  foodstuffs.  The  treatment  is  symptomatic  and  elimina- 
tive;  the  administration  of  10  to  15  grains  (0.66  to  i.o)  of  ground  calcined 
deer  horn  every  six  hours  is  suggested.  Calomel  should  not  be  given  as  a 
purge;  castor  oil  or  magnesium  sulphate  is  preferable.  Stimulation  is 
usually  necessary,  here  alcohol,  strychnine,  etc.,  may  be  employed.  The 
diet  should  be  arranged  in  accordance  with  the  principles  usual  in  infectious, 
diseases. 

GONORRHCEAL  INFECTIONS. 

The  consideration  of  infection  of  the  male  urethra  and  of  the  vagina  with 
the  gonococcus  is  without  the  scope  of  this  work  but  this  fact  does  not  render 
less  the  importance  of  the  disease.  Gonorrhoea  is  without  doubt  one  of  the 
greatest  scourges  with  which  the  human  race  has  to  contend  and  its  effects 
reach  far  beyond  the  seat  of  the  primary  inflammation.     The  extent  of  the 


142  THE    INFECTIOUS    DISEASES. 

ravages  of  the  infection  are  prominently  brought  to  notice  by  the  recent 
statement  of  an  eminent  gynaicologist  that  probably  not  less  than  80  percent, 
of  the  married  women  of  New  York  City  are  suffering  from  pelvic  disorders 
of  various  characters,  the  result  of  infection  from  their  husbands  whose  youth- 
ful or  later  indiscretions  become  thus  responsible  for  ills  that  render  a  woman's 
life  miserable  and  end  in  sterility  or  even  more  serious  conditions.  The 
time  is  past  when  a  specific  urethritis  is  to  be  looked  upon  as  little  more  grave 
than  a  cold  in  the  head  and  considered  a  part  of  the  education  of  every  young 
man.  It  has  been  demonstrated  that  the  gonococcus  remains  active  in  the 
urethral  discharge  long  after  this  ceases  to  be  purulent  in  character  and  even 
after  years,  when  the  host  of  this  insidious  organism  believes  himself  wholly 
cured,  is  capable  of  as  much  mischief  as  when  the  infection  was  in  its  early 
stages. 

GONORRHCEAL  SEPTICAEMIA  AND  PYEMIA. 

These  conditions  do  not  differ,  so  far  as  symptoms  are  concerned,  from 
analogous  states  resulting  from  other  microbic  infections,  except  that  they  are 
associated  with  genito-urinary  inflammations.  The  gonococcus  may  be  dem- 
onstrable in  the  blood  and  the  course  of  the  affection  varies  in  severity.  The 
irregular  temperature  may  continue  for  a  number  of  weeks  and,  unless  the 
endocardium  becomes  involved,  recovery  may  take  place;  on  the  other  hand 
rapidly  fatal  infections  occur  usually  associated  with  localized  pus  collections 
in  different  parts  of  the  genito-urinary  system. 

The  most  important  and  frequent  local  manifestations  of  general  gonor- 
rhoeal  infection  are  gonococcal  endocarditis  and  arthritis. 

a.  GonorrhcBal  endocarditis  is  a  serious  condition  and  for  its  more 
complete  discussion  the  reader  is  referred  to  the  section  upon  malignant 
endocarditis  (p.  569).  Gonococci  may  be  demonstrated  in  the  blood  and  in 
the  ulcerations  or  verrucous  growths  upon  the  valves.  Other  cardiac  lesions 
such  as  pericarditis  and  myocarditis  may  be  associated  with  the  endocardial 
inflammation. 

b.  Gonorrhoeal  arthritis  is  a  septic  inflammation  of  a  joint  due  to  the 
gonococcus.  It  is  not  an  uncommon  sequence  of  gonorrhoeal  infection  and 
is  serious  in  its  effects.  It  usually  occurs  during  the  attack  of  a  gonorrhoeal 
infection  of  the  urethra  or  vagina  but  has  been  observed  to  follow  gonorrhoeal 
conjunctivitis  in  children.  It  seems  to  be  more  common  in  men  than  in 
women  and  may  not  appear  until  late  in  the  attack  or  even  during  the  chronic 
stage  of  the  infection.  One  or  more  joints  may  be  attacked  and  the  inflam- 
mation at  times  involves  articulations  seldom  affected  by  acute  articular 
rheumatism,  such  as  the  inter-vertebral,  temporo-maxillary,  sterno-clavicular, 
etc. 

Pathology.      The   morbid   changes  present   are  by   no   means   uniform. 


GONORRHCEAL    INFECTIONS.  I43 

The  inflammation  may  involve  the  tissues  without  the  joint  and  spread  along 
the  tendon  sheaths  or  it  may  be  intra-articular.  In  each  case  the  synovial 
membranes  are  affected  and  pus  may  or  may  not  be  present.  From  the  ex- 
udate the  gonococcus  may  be  grown  and  this  organism  is  at  times  associated 
with  the  common  bacteria  of  suppuration. 

Symptoms.  A  number  of  different  clinical  varieties  of  gonorrhoeal  arthritis 
have  been  described  but  it  will  suffice  to  mention  two  principal  types,  the 
acute  and  chronic. 

a.  Acute  gonorrhoeal  arthritis  differs  in  severity  in  different  instances. 
It  may  be  evidenced  only  by  slight  pain  and  stiffness  or  in  the  more  acute 
infections,  one  or  more  joints  may  become  suddenly  involved  in  severe  inflam- 
mation with  pronounced  pain,  tenderness,  redness  and  swelling.  Intra-articular 
fluid  may  be  demonstrable  upon  palpation.  If  the  exudate  is  purulent  con- 
stitutional symptoms  are  usually  present.  In  the  extra-articular  form  the 
inflammation  is  prone  to  extend  along  the  sheaths  of  the  tendons.  The 
symptoms  are  persistent  and  ankylosis,  more  or  less  marked,  may  follow. 

In  general  gonorrhoeal  infection  suppurative  arthritis  and  endocarditis 
may  co-exist. 

h.  Chronic  gonorrhoeal  arthritis.  In  this  condition  there  may  be  a 
serous  joint  effusion  or  a  chronic  inflammatory  process  may  involve  the  intra- 
and  extra-articular  structures;  in  the  former  condition  there  may  be  little  or 
no  pain  but  in  the  latter  pain  is  usually  present  and  is  associated  with  swelling 
extending  to  some  distance  above  and  below  the  joint. 

Gonorrhoeal  arthritis  is  especially  prone  to  affect  the  knees,  wrists  and 
ankles  and  relapses  are  frequent.  Its  course  is  often  protracted  and 
obstinate. 

Complications  are  not  rare  and  may  be  serious.  Iritis,  pericarditis,  myo- 
carditis, endocarditis,  pleurisy  and  septic  pneumonia  have  been  observed. 

The  diagnosis,  when  there  is  present  a  urethral  discharge,  is  simple,  but 
in  other  instances  must  be  based  upon  the  presence  of  gonococci  in  the  blood 
or  in  the  articular  effusion.  In  the  acute  form  the  pain  is  more  severe  and  the 
tendency  to  peri-articular  involvement  greater  than  in  acute  articular  rheu- 
matism; the  latter  is  said  to  be  more  likely  to  affect  several  joints  in  succes- 
sion while  an  arthritis  of  a  single  joint  is  to  be  considered  as  more  prob- 
ably of  gonorrhoeal  origin. 

Treatment  consists  first  in  the  employment  of  local  measures  with  the 
intent  of  curing  the  local  genital  inflammation  if  this  is  present.  In  general 
constitutional  infection  iodine  is  the  most  reliable  agent  and  good  results 
may  be  obtained  by  the  administration  of  the  syrup  of  hydriodic  acid  in  doses 
of  \  an  ounce  (15.0)  half  an  hour  before  meals  in  two  ounces  (60.0)  of  water. 
The  mode  and  time  of  administration  are  important  since  the  drug  is  some- 
what irritant  to  the  stomach.     If  not  well  borne  10  percent,  of  resuhlimed 


144  THE    INFECTIOUS    DISEASES. 

iodine  in  oil  of  sesame  may  be  employed  in  doses  of  lo  to  20  minims  (0.66  to 
1.33)  every  three  hours.  Iodine  so  given  is  taken  into  the  blood  stream  as  is 
proven  by  the  fact  that  the  saliva  gives  the  starch-iodine  reaction  within  20 
minutes  after  the  administration  of  a  dose  per  rectum.  The  above  treatment 
is  also  to  be  prescribed  in  gonorrhoeal  arthritis  and  endocarditis  in  connection 
with  inunctions  of  colloidal  silver  ointment  (unguentum  Crede),  J  an  ounce 
(15.0)  into  each  affected  joint  three  times  a  day.  Within  6  to  10  days  after 
the  commencement  of  such  treatment  a  noticeable  improvement  in  the  arthritic 
symptoms  should  be  apparent. 

Syrup  of  iron  iodide  in  doses  of  10  minims  (0.66)  to  one  drachm  (4.0)  three 
times  a  day  has  also  been  recommended  and  the  internal  administration  of 
the  preparations  of  mercury  has  its  advocates.  The  salicylates  seem  to  be 
wholly  useless. 

Favorable  results  have  been  reported  from  the  treatment  of  gonorrhoeal 
arthritis  by  means  of  Bier's  method  of  passive  congestion.  The  technique 
of  the  treatment  consists  in  the  application  of  an  Esmarch  bandage  just  long 
enough  to  encircle  the  limb  two  or  three  times  at  the  desired  tension  and 
provided  with  strap  and  buckle  at  either  end.  The  bandage  is  applied  just 
above  the  affected  joint  and  is  secured  when  the  desired  degree  of  congestion 
has  been  obtained.  The  skin  may  be  protected  by  a  few  turns  of  an  ordinary 
bandage,  and  to  avoid  stasis  in  parts  where  it  is  not  needed,  that  part  of  the 
limb  which  lies  peripherally  to  the  infected  area  may  be  snugly  bandaged. 
The  congested  limb  should  not  be  allowed  to  become  cold  to  the  touch  and 
the  patient  should  not  be  made  uncomfortable.  The  congestion  should  be 
continued  for  from  10  to  12  hours  at  a  time  and,  while  the  strap  is  off,  the 
limb  should  be  elevated  to  reduce  the  oedema  which  the  constriction  has 
produced.  Upon  the  subsidence  of  acute  symptoms,  massage  and  passive 
motion  should  be  instituted.  In  general  the  duration  of  the  stasis  should 
depend  upon  the  effect  obtained.  If  the  pain  is  relieved  in  an  hour  or  two 
and  motion  becomes  less  difi&cult,  this  length  of  time  is  sufficient,  but  if  the 
symptoms  soon  return  a  longer  application  of  the  bandage  is  necessary.  In 
the  chronic  effusion  following  acute  inflammation  this  form  of  treatment  is 
useless. 

With  regard  to  local  treatment  other  than  that  by  the  silver  inunctions, 
absolute  rest  of  the  affected  joints  is  to  be  insisted  upon  and  it  may  be  advisable 
to  apply  a  splint.  This,  however,  should  not  be  allowed  to  remain  in  place 
long  enough  to  cause  ankylosis.  The  continued  application  of  a  10  percent, 
ichthyol  ointment  in  the  intervals  of  the  silver  inunctions  may  assist  in  the 
relief  of  pain. 

The  more  chronic  forms  of  joint  involvement  may  be  relieved  by  counter- 
irritation  by  blisters  or  the  thermo-cautery,  baking  in  the  hot  air  apparatus 
is  to  be  recommended  and  the  absorption  of  the  effusion  may  be  facilitated 


SYPHILIS.  145 

bv  massage  and  passive  movements.  These  last  also  are  an  excellent  means 
combating  the  tendency  to  ankylosis. 

Constitutional  treatment  by  means  of  iron,  arsenic,  quinine  and  strych- 
nine is  important,  especially  in  the  chronic  infections. 

Surgical  treatment,  consisting  of  opening  the  joint,  evacuating  the  effusion 
and  irrigating  with  mild  antiseptics  or  sterile  saline  solution,  has  its  advocates 
and  in  many  instances  has  achieved  excellent  results. 

SYPHILIS. 

Synonyms.     The  Pox;  Lues  Venerea. 

Definition.  A  specific  constitutional  disease  of  slow  course  resulting 
from  inoculation  or  from  hereditary  transmission.  The  disease,  when  inocu- 
lated, is  known  as  acquired  syphilis  and,  when  conferred  by  inheritance,  as 
hereditary  sj'philis.  In  the  acquired  form  there  appears  at  the  site  of  inocula- 
tion the  so-called  initial  lesion  or  chancre  which  is  usually  an  ulcer  possessing 
special  characteristics.  This  is  followed  within  a  month  or  two  by  consti- 
tutional manifestations  and  lesions  of  the  skin  and  mucous  membranes,  the 
symptoms  of  the  secondary  stage,  and  after  months  or  years  by  gummatous 
growths  in  the  various  tissues  and  organs,  the  tertiary  lesions,  and  finally  there 
may  appear  various  morbib  conditions  in  the  nervous  system  such  as  locomotor 
ataxia  and  general  paresis,  which  are  known  as  quaternary  lesions. 

.etiology.  While  several  micro-organisms  have  been  described,  which 
have  been  thought  responsible  for  this  disease,  their  connection  with  the  infec- 
tion has  not  yet  been  definitely  proven.  Recently  Schaudinn  and  Hoffmann 
have  drawn  attention  to  micro-organisms  of  the  genus  spirochaeta,  which  they 
have  found  in  primary  and  secondary  syphilitic  lesions,  both  at  their  surfaces 
and  in  their  deeper  parts  and  in  the  adjacent  lymphatic  glands.  The  former 
observer  considers  that  the  spirochcetae  are  related  rather  to  the  protozoa 
than  to  the  bacteria  and  must,  therefore,  be  clearly  distinguished  from  the 
spirilla.  He  describes  two  varieties,  one  found  only  in  syphihtic  lesions,  the 
other,  saprophytic  in  nature  and  constantly  met  in  stagnant  secretions  such 
as  those  occurring  about  the  genitals.  The  former  is  termed  the  spirochcsta 
pallida,  the  other  the  spirochceta  refringens.  The  former  is  much  the  smaller 
and  is  seen  only  with  the  higher  powers  of  the  microscope  and  even  then, 
with  diflBculty. 

Metchnikoff  and  Roux  have  found  identical  forms  in  experimental  syphilitic 
lesions  in  monkeys  and  other  observers  have  wholly  confirmed  the  work  of 
Schaudinn  and  Hoffmann.  The  spirochaeta  pallida  has  been  found  in  the 
blood  and  organs  of  infants  suffering  from  congenital  syphilis  and  in  acquired 
syphilis  in  the  blood  procured  by  splenic  puncture  on  the  day  before  the 
roseolar  rash  appeared,  proving  that  it  reaches  the  skin  through  the  blood- 


146  THE    INFECTIOUS    DISEASES. 

vessels.  Later  it  has  been  demonstrated  in  the  circulating  blood.  In  acquired 
syphilis  it  is  found  only  during  the  primary  and  secondary  stages,  practically 
never  during  the  tertiary.  Most  authorities  agree  that  the  spirochaeta  is  never 
to  be  found  in  non-syphilitic  lesions,  one  or  two  have,  however,  encountered 
it  in  other  conditions.  The  balance  of  evidence  seems  to  favor  the  aetiologic 
relation  of  the  spirochaeta  pallida  to  syphilis  and  the  most  conservative  admit 
that  it  probably  plays  some  part  in  the  causation  of  the  disease. 

Syphilis  is  an  extremely  contagious  disease  but  a  solution  of  the  continuity 
of  skin  or  mucous  membrane  is  necessary  to  its  inoculation.  The  secretions 
of  the  primary  and  secondary  lesions  as  well  as  the  blood  of  the  syphilitic 
patient  are  capable  of  transmitting  the  infection  but  the  authorities  differ  as 
to  whether  the  products  of  the  tertiary  manifestations,  the  gummata,  are 
infectious.  It  is  probable,  however,  that  they  are.  Normal  secretions,  such  as 
milk,  tears,  etc.,  unless  contaminated  by  the  secretions  of  specific  lesions,  are 
not  capable  of  conferring  the  disease.  The  spermatozoa  or  ova  of  syphilitic 
individuals  are,  however,  infectious. 

In  most  instances  the  acquired  form  of  the  disease  results  from  sexual 
congress  but  the  infection  may  be  acquired  innocently  through  the  use  of 
infected  drinking  cups  or  other  utensils,  by  kissing,  by  the  physician  during 
operation  or  while  handling  infected  patients,  and  in  various  other  ways. 
The  wet  nurse  may  be  infected  by  the  syphilitic  child,  the  initial  lesion  appear- 
ing upon  or  near  the  nipple  and  the  disease  has  been  transmitted  by  vaccina- 
tion with  humanized  virus. 

Hereditary  specific  disease  is  most  commonly  transmitted  through  the 
father  in  which  case  it  is  termed  sperm  infection.  A  syphilitic  father  may 
beget  diseased  offspring  during  the  tertiary  stage  when  all  symptoms  seem  to 
have  disappeared  but  he  is  most  likely  to  beget  a  syphilitic  child  soon  after 
the  beginning  of  his  infection;  on  the  other  hand  the  child  of  a  syphilitic  father 
mav  show  no  evidence  of  the  disease  when  begotten  during  the  tertiary  stage 
or  even  when  begotten  while  the  disease  is  at  its  height.  No  certain  assertion 
can  be  made  that  a  father  once  infected  with  syphilis  will  not  transmit  the 
disease  to  his  children  but  it  may  be  stated  that  the  greater  the  period  since 
the  occurrence  of  the  initial  lesion,  the  less  likely  are  the  children  to  be 
affected.  At  least  three  years,  during  which  the  individual  should  undergo 
proper  treatment,  should  elapse  between  the  initial  lesion  and  marriage. 

Syphilis  transmitted  through  the  mother  is  termed  germ  infection  and  is 
more  likely  to  prove  fatal  than  sperm  infection.  A  child  may  also  be  infected 
during  its  passage  through  the  parturient  canal  or,  the  mother  acquiring  the 
disease  during  pregnancy,  the  child  may  escape  or  may  become  infected 
through  the  placenta.  It  is  a  curious  fact  (Colles'  law)  that  a  syphilitic  infant 
born  of  a  non-syphilitic  mother  cannot  transmit  the  disease  to  her,  even 
though  she  nurse  it  while  there  exist  syphilitic  lesions  upon  its  lips  or  within 


SYPHILIS,  147 

its  mouth.  This  is  probably  due  to  an  immunity  possessed  by  the  mother 
and  which  has  been  conferred  without  the  manifestation  of  any  symptonis 
whatever. 

Children  born  of  parents,  both  of  whom  are  syphiUtic,  are  very  unlikely  to 
escape  the  disease. 

Pathology  of  acquired  syphilis.  The  lesions  of  this  form  of  the 
infection  occur  in  stages,  the  first  being  that  of  the  primary  lesion  or  chancre. 
This  appears  at  the  site  of  the  inoculation  and  usually  about  three  weeks 
after  this  occurrence.  At  first  it  consists  of  an  abrasion  upon  which  a  papule 
or  vesicle  appears;  later  this  disintegrates  at  its  center  and  an  ulcer  results,  the 
base  and  edge  of  which  are  firm  and  indurated.  It  varies  in  size  and  may 
be  unnoticed  if  it  occurs  within  the  urethra  and  is  especially  likely  to  be  over- 
looked in  the  female.  In  the  male  it  is  usually  upon  the  penis  and  frequently 
upon  the  prepuce,  while  in  females  a  frequent  site  is  upon  the  labia  or  upon 
the  cervix.  Microscopically  the  indurated  tissue  is  found  to  be  the  result  of 
an  infiltration  of  the  connective  tissue  with  small  round  cells,  some  of  which 
may  later  become  epithelioid  or  even  giant  cells.  The  intima  of  the  vessels 
is  thickened  and  the  nerve  fibres  may  be  the  seat  of  pathological  change. 
The  neighboring  lymph  ganglia  are  enlarged,  hardened  and  may  sup- 
purate. 

The  lesions  of  the  secondary  stage  consist  of  a  cutaneous  eruption  or  syphil- 
ide.  This  rash  occurs  in  a  variety  of  different  forms,  macular,  papular, 
pustular,  squamous  and  tubercular;  the  hue  of  these  is  characteristic  and 
may  be  described  as  ham  or  copper  color.  The  macular  syphilide  usually 
lasts  one  or  two  weeks  and  is  especially  apparent  upon  the  chest,  abdomen 
and  flexor  surfaces  of  the  arms;  the  papular  eruption  occurs  upon  the  face 
as  well  as  upon  the  body,  and  like  the  others,  tends  toward  a  symmetrical  distri- 
bution. The  pustular  rash  is  not  unlike  that  of  variola  and  the  squamous 
syphilide  possesses  nothing  typical  except  its  color;  it  is  a  rare  form  and  its 
favorite  situation  is  upon  the  extensor  surfaces  of  the  limbs.  All  forms 
of  the  eruption  are  characterized  by  a  tendency  to  symmetrical  distribution 
and  to  leave  behind  a  more  or  less  permanent  discoloration. 

With  the  cutaneous  manifestations  an  involvement  of  the  mucous  membranes 
and  of  moist  skin  surfaces  occurs;  this  is  termed  the  mucous  patch  or  broad 
condyloma  {condyloma  latum).  These  appear  upon  the  buccal  and  pharyngeal 
mucous  membranes  and  at  the  muco-cutaneous  junctions  about  the  lips, 
anus,  etc.,  and  consist  of  a  cellular  infiltration  of  the  epidermis  and  corium. 
The  mucous  patch  is  a  flat  or  slightly  convex  pearl  colored  elevation,  with  a 
surface  resembling  mucous  membrane,  the  secretion  of  which  is  highly 
contagious.  The  condylomata  are  exaggerated  mucous  patches  and  consist 
of  rounded  discs,  reddish  or  grayish  in  color,  granular  of  surface  and  slightly 
elevated.     The   secretion    of   these    is    also    pronouncedly    infectious.     The 


148  THE    INFECTIOUS    DISEASES. 

venereal  wart  or  condyloma  acuminatum  is  also  a  manifestation  of  the  second- 
ary stage. 

The  lesions  of  the  third  stage  may  involve  any  of  the  deeper  tissues  or 
organs  and  consist  of  discrete  tumors  (gummata).  These  are  usually  firm 
in  consistency  and  vary  in  size  from  that  of  a  pin  point  to  a  diameter  of  from 
one  to  tv^^o  inches  (3  to  5  cm.).  On  section  they  are  seen  to  consist  of  a  central 
area,  firm  and  caseous,  surrounded  by  a  layer  of  fibrous  tissue  outside  which 
is  an  external  layer  of  cellular  granulation  tissue. 

Such  gummata  are  common  in  the  skin,  muscles,  periosteum,  bone — where 
they  are  termed  nodes — and  in  the  connective  tissue  of  the  brain  and  viscera. 
When  situated  in  submucous  tissues  ulceration  or  suppuration  may  result 
with  destruction  of  tissue,  such  as  is  observed  in  syphilitic  disease  of  the 
nasal  or  palatal  bones. 

Arterial  changes  also  occiu*  as  a  result  of  tertiary  syphilis.  These  will  be 
considered  in  the  section  devoted  to  arterial  disease  (p.  606). 

Symptoms  of  acquired  syphilis.  These  occur  in  stages  and  are  intimately 
associated  with  the  morbid  changes  above  described.  The  incubation 
period  of  the  disease  is  usually  about  three  weeks,  that  is  to  say  about  this 
time  intervenes  between  the  inoculation  and  the  appearance  of  the  primary 
lesion  or  chancre.  This  and  the  associated  glandular  enlargements  have 
been  considered. 

The  symptoms  of  the  secondary  stage  usually  appear  in  from  6  to  12  weeks. 
First  there  is  a  pharyngeal  congestion  with  soreness  of  the  throat.  Sluggish 
ulcerations  of  a  gray  color  are  seen  upon  the  mucous  membranes  of  the  throat 
and  larynx,  those  in  the  latter  situation  being  likely  to  cause  deformity  of 
the  part  upon  healing.  Mucous  patches  and  condylomata  may  be  present. 
There  is  usually  a  moderate  febrile  movement  which  seldom  rises  higher 
than  101°  F.  (38.3°  C.)  although  temperatures  of  104°  to  105°  F.  (40°  to 
4o.5°C.)  have  been  observed.  The  temperature  is  usually  continuous  or 
remittent;  less  frequently  it  is  intermittent  and  may  be  mistaken  for  malaria. 
The  pharyngeal  inflammation  may  involve  the  middle  ear  by  extension 
through  the  Eustachian  tube. 

Cutaneous  lesions  now  appear;  the  most  frequent  is  the  macular  syphilide 
previously  mentioned.  The  rash  lasts  for  two  or  three  weeks  and  may  be 
followed  by  other  forms  of  the  syphilitic  eruption.  Recurrences  of  the  rash 
may  occur  at  intervals  even  as  late  as  11  years  after  the  initial  lesion.  The 
hair  often  falls  and  there  may  be  a  syphilitic  onychia.  Iritis  is  common 
and  may  be  serious.  Choroiditis  and  retinitis  are  more  rarely  observed. 
Joint  symptoms,  at  times  so  marked  as  to  suggest  acute  articular  rheuma- 
tism, and  pains  in  the  Hmbs  are  not  unusual.  Jaundice,  nephritis,  parotitis 
and  epididymitis  may  occur.     Anaemia  is  very  common. 

The    tertiary   stage    cannot   be   distinctly   separated   from   the  secondary. 


SYPHILIS.  149 

During  this  stage  the  characteristic  manifestations  are  various  cutaneous 
eruptions,  amyloid  degenerations  and  involvement  of  the  viscera  by  gummy 
tumors. 

The  tertiary  syphilides  are  usually  deep  seated,  tend  to  ulcerate  and  may 
subsequently  heal,  leaving  scars.  They  may  be  scattered  over  the  body  and 
are  seldom  symmetrical.  Syphilitic  rupia  consists  of  pustules,  ulcerated 
at  the  base  and  covered  by  a  laminated  crust. 

Hereditary  syphilis  may  be  evidenced  by  all  the  morbid  changes  and 
symptoms  which  are  met  in  the  acquired  lues  except  the  primary  lesion. 
Still-births  and  abortions  are  very  frequent  consequences  of  fcetal  syphilis 
but  the  appearance  of  the  newly-born  syphilitic  child  is  often  that  of  health, 
the  syphilitic  manifestations  appearing  after  a  month  or  two;  at  other  times 
the  subject  of  syphilitic  inheritance  is  poorly  developed,  ill-nourished  and 
shriveled  in  aspect;  skin  eruptions  are  frequent  and  the  so-called  pemphigus 
neonatorum,  a  bullous  rash  about  the  wrists  and  ankles,  hands  and  feet,  is 
typical.  The  liver  and  spleen  are  enlarged,  the  lips  are  wrinkled,  fissured 
and  ulcerated  and  the  child  snuffles;  the  discharges  are  infective  and  may  be 
sero-purulent  or  sero-sanguinolent;  bone  necrosis  at  the  bridge  of  the  nose 
may  lead  to  the  characteristic  deformity.  Bony  nodes  may  be  present  upon 
the  skull  (Parrot's  sign).  Middle-ear  involvement  may  take  place  through  the 
Eustachian  tube.  If  the  child  is  apparently  healthy  at  birth  the  above  described 
symptoms  may  appear  up  to  the  sixth  month. 

The  cartilages  of  the  ribs  and  those  of  the  epiphyses  of  the  long  bones 
are  very  commonly  affected  and  even  epiphyseal  separation  may  take  place. 
The  child  nurses  poorly,  is  restless  and  a  typical  cry,  described  as  harsh  and 
high-pitched,  has  been  observed.  Haemorrhages  into  the  skin,  from  the  mucous 
membranes  or  from  the  umbilicus  {syphilis  hcBmorrhagica  neotmtorum)  are  a 
rather  rare  manifestation. 

If  the  child  survives  its  growth  it  is  stunted  and  is  likely  to  present  the 
appearance  of  premature  age.  Under  proper  treatment  recovery  may  take 
place  and,  while  development  may  be  delayed,  the  disease  may  not  give  further 
symptoms.  As  a  rule,  however,  further  s^'philitic  manifestations  appear 
at  the  time  of  second  dentition  or  at  puberty.  The  subject  of  hereditary 
syphilis  who  survives  childhood  is  under-developed  and  looks  younger  than 
his  age  (infantilism),  the  frontal  region  is  prominent,  the  frontal  bosses  protrude, 
the  bridge  of  the  nose  is  depressed  (saddle-nose)  and  its  tip  turned  up.  Cran- 
ial asymmetry  may  be  present  and  the  teeth  are  notched  (Hutchinson  teeth). 
Those  particularly  affected  are  the  upper  central  incisors  which  are  peg- 
shaped  and  notched  at  the  edges,  the  enamel  often  being  wanting  over  the 
notches. 

Amongst  other  manifestations  which  are  late  in  appearance  are  bone 
deformities,  especially  of  the  tibiae  which  are  thickened  and  curved  antero- 


150  THE    INFECTIOUS    DISEASES. 

posteriorly,  the  convexity  being  forward;  nodes  may  be  present  upon  the 
bones;  interstitial  keratitis,  iritis,  syphilitic  deafness  and  gummata  of  the 
nervous  system  or  of  the  viscera  may  be  observed. 

The  diagnosis  of  syphilis  is  not  diflBcult  in  the  presence  of  a  history  of 
exposure  or  of  heredity.  There  may  be  difficulty  in  deciding  upon  the  char- 
acter of  the  initial  sore,  consequently  it  is  vi^ell  to  wait  until  the  appearance  of 
secondary  lesions  before  beginning  treatment.  The  test  of  treatment  by 
mercury  and  iodine  will  usually  clear  the  diagnosis  in  doubtful  cases. 

Justus'  test  consists  in  first  estimating  the  haemoglobin  content  of  the  blood, 
then  ordering  a  mercurial  inunction  or  injection  and  subsequently  making  a 
second  haemoglobin  estimation.  In  instances  of  syphilis  there  will  be  a  reduc- 
tion of  from  10  to  20  percent.  This  test  is  based  upon  the  fact  that  mercury 
causes  a  destruction  of  the  haemoglobin  which  is  rapidly  replaced  under 
normal  conditions.  In  the  syphilitic  subject,  however,  this  power  of  repro- 
duction is  greatly  diminished. 

The  prognosis  in  acquired  syphilis  under  early  and  proper  treatment  is 
good  but  the  length  of  time  necessary  to  assure  a  cure  is  at  least  two  years; 
consequently  syphilitics  should  be  strongly  advised  against  marriage  within 
two  years  after  the  appearance  of  the  initial  lesion;  if  active  symptoms  remain 
at  the  end  of  this  period  marriage  should  be  forbidden  as  long  as  these  per- 
sist. Even  in  individuals  who  have  undergone  thorough  treatment  it  is 
not  unusual  to  observe  late  complications  referable  to  the  nervous  system. 
The  prognosis  of  infantile  syphilis  is  not  so  good  as  that  of  the  infection  in 
adults  and  hereditary  infantile  sj^hilis  is  much  more  grave  than  that  acquired 
after  birth.  Even  the  subjects  of  hereditary  syphilis  who  survive  are  ren- 
dered so  weak  of  constitution  by  the  disease  that  they  fall  an  easy  prey  to 
even  slight  intercurrent  affections. 

Treatment.  The  prophylaxis  of  syphilis  acquired  through  illicit  inter- 
course can  only  be  instituted  by  insisting  upon  the  absolute  importance  of 
sexual  purity.  The  physician  who  advises  the  performance  of  the  sexual  act 
under  illegitimate  conditions  cannot  be  too  strongly  condemned.  The 
young  man  who  finds  his  fleshly  lusts  too  vigorous  to  be  denied  may  do  much 
to  subjugate  them  by  working  hard  physically  and  mentally. 

Practitioners  associating  with  syphilitics  in  a  professional  capacity  cannot 
be  too  guarded  in  their  handling  of  specific  lesions. 

Much  may  be  done  toward  the  prevention  of  hereditary  syphilis  by  treating 
the  mother  during  pregnancy  if  she  has  ever  been  affected  with  the  disease 
or  if  the  father  is  syphilitic.  Syphilitic  lesions  of  the  genital  tract  should 
be  cleansed  and  cauterized  previous  to  labor.  Should  the  child  be  born 
healthy  it  should  never  be  nursed  by  a  suspected  mother  or  wet  nurse,  it  should 
not  be  kissed  by  nor  sleep  with  diseased  parents  and  the  greatest  care  should 
be  exercised  in  rendering  utensils  and  other  objects  with  which  the  child  comes 


SYPHILIS.  151 

into  contact  above  reproach.  No  syphilitic  child  should  be  allowed  to  nurse 
from  a  healthy  woman. 

The  treatment  of  the  primary  lesion  consists  in  the  endeavor  to  heal  it  as 
soon  as  possible.  This  is  to  be  accomplished  by  simple  cleanliness.  The 
sore  should  be  washed  with  a  i  to  2  or  3,000  mercury  bichloride  solution 
several  times  daily  and  kept  dusted  with  equal  parts  of  bismuth  and  calomel, 
iodoform — which  should  be  used  with  care  since  an  idiosyncrasy  to  this  drug 
is  not  rare — or  other  bland  antiseptic  powder.  A  dressing  of  mercurial 
ointment  may  also  hasten  the  healing  process.  Cauterization  or  excision 
of  the  lesion  is  useless 

The  secondary  lesions  should  also  be  treated  by  the  application  of  cleansing 
agents.  The  teeth  should  be  frequently  brushed  and  a  mouth  wash  of  ^ 
saturated  solution  of  potassium  chlorate,  which  not  only  has  a  beneficial 
effect  upon  the  mucous  patches  but  is  prophylactic  against  mercurial  stomatitis, 
should  be  frequently  employed.  The  use  of  tobacco  and  alcohol  should  be 
forbidden.  Ulcers  should  be  cleansed  with  the  mercury  bichloride  solution, 
dressed  with  mercurial  ointment  or  dusted  with  calomel  and,  if  necessary, 
touched  with  silver  nitrate  stick  or  solution;  the  latter  may  also  be  employed 
upon  the  mucous  patches  in  the  mouth.  Condylomata  should  be  kept  thor- 
oughly cleansed  and  either  dusted  with  the  powders  mentioned  above  or 
dressed  with  mercurial  ointment. 

Constitutional  treatment  should  be  instituted  as  soon  as  the  diagnosis  is 
assured  and  consists  in  the  administration  of  mercury  during  the  secondary 
stage  and  of  iodine  during  the  tertiary.  The  two  may  often,  however,  be 
given  together  with  advantage  dvuring  the  second  stage.  Mercury  may  be 
administered  in  various  ways;  of  these  one  of  the  best  and  one  of  the  most 
commonly  employed  is  by  inunctions.  Its  disadvantages  are  that  it  takes 
considerable  care  and  time  and  is  not  cleanly.  The  plan  is  as  follows:  The 
patient  should  take  a  warm  bath  daily  to  cleanse  the  skin  and  render  it  more 
capable  of  absorption.  After  the  bath  a  drachm  (4.0)  of  the  official  mercury 
ointment  is  thoroughly  rubbed  into  the  skin,  the  friction  to  be  continued 
until  the  ointment  has  entirely  disappeared.  It  is  well  to  choose  a  different 
site  for  the  inunction  each  day,  first  taking  the  inside  of  one  thigh,  next  that 
of  the  other,  the  inner  aspect  of  the  arms,  then  the  sides  of  the  chest,  etc. 
When  these  parts  have  been  exhausted  the  list  should  be  begun  again.  The 
rubbing  should  last  at  least  J  hour.  Hairy  parts  should  be  avoided,  since 
the  follicles  offer  favorable  foci  for  the  beginning  of  a  mercurial  eczema, 
and  the  use  of  a  potassium  chlorate  mouth  wash  is  necessary  to  prevent 
stomatitis.  Should  this  occiu*,  as  evidenced  by  soreness  of  the  gums  and  teeth, 
foul  breath,  etc.,  the  inunctions  should  be  stopped  for  a  week  or  more  until 
the  buccal  symptoms  disappear.  The  frictions  should  be  continued  for 
about  a  month,  when,  if  the  syphilitic  symptoms  have  subsided,  they  may  be 


152  THE    INFECTIOUS    DISEASES. 

omitted  and  internal  treatment  begun.  Here  mercury  may  be  given  in 
various  forms,  the  preparations  most  usually  employed  being  the  yellow 
iodide  (protiodide)  gr.  ^  (0.016),  the  red  iodide  (biniodide)  gr.  |  (0.004) 
or  the  bichloride  gr.  yW  (0.005)  three  times  a  day.  If  the  patient  can  be 
made  to  understand  how  essential  continued  treatment  is  the  tertiary  mani- 
festations may  be  prevented  from  making  their  appearance.  To  accomplish 
this  desirable  object,  however,  the  treatment  must  be  continued  for  an  indefi- 
nite period. 

Various  substitutes  for  the  inunction  method  of  treatment  have  been  advo- 
cated and  the  one  most  in  use  at  present  is  that  by  hypodermatic  injection 
of  various  mercury  salts.  The  injections  are  given  by  means  of  a  long  needle 
attached  to  the  ordinary  hypodermic  syringe,  the  solution  is  thrown  into  the 
deeper  muscular  structures  and  the  procedure  must  be  carried  out  under 
the  most  thorough  aseptic  and  antiseptic  precautions.  The  sites  usually 
selected  are  the  buttock,  the  sides  of  the  thorax  or  the  flanks.  Such  solutions 
as  the  following  may  be  employed:  Mercury  bichloride  0.2  parts,  sodium 
chloride  2  parts,  distilled  water  to  20  parts.  Of  this  a  daily  injection  of  15 
minims  (i.o)  may  be  given.  Mercury  benzoate  0.25  parts,  sodium  chloride 
and  cocaine  hydrochloride  of  each  0.06  parts,  distilled  water  to  30  parts; 
peptone  and  ammonium  chloride  of  each  0.3  parts,  merciu-y  bichloride 
0.2  parts,  glycerin  5  parts,  distilled  water  15  parts;  neutral  mercury  lactate 
I  part,  distilled  water  100  parts;  mercury  cyanide  o.i  part,  distilled  water 
20  parts;  mercury  salicylate  4  parts,  benzoinol  30  parts;  of  all  the  above  the 
dosage  is  15  minims  (i.o)  which  may  be  injected  daily.  In  very  grave  infections 
the  dosage  may  be  doubled  or  15  minims  (1.0)  of  a  i  percent,  mercury  cyanide 
solution  maybe  introduced  slowly,  directly  into  a  vein;  a  mixture  of  calomel 
I J  parts  and  sterile  oil  15  parts  may  be  given  subcutaneously  in  doses  of  15 
minims  (i.o)  about  once  a  week.  The  treatment  by  injections  is  especially 
indicated  when  it  is  necessary  to  mercurialize  the  patient  without  delay,  in 
patients  whose  skin  is  badly  affected  by  inunctions  and  the  internal  adminis- 
tration of  mercury  disturbs  the  digestion  and  in  instances  where  the  disease 
resists   other   methods. 

Mercurial  fumigations  have  had  a  certain  vogue.  The  patient,  sitting  on 
a  chair,  is  surrounded  to  the  neck  by  blankets  arranged  in  the  form  of  a  tent. 
An  alcohol  lamp  is  placed  under  the  chair  and  upon  this  is  set  a  metal  plate 
containing  about  ^  drachm  (2.0)  of  powdered  calomel.  The  seance  should 
last  about  20  minutes  during  which  the  calomel  is  volatilized  by  the  heat  of 
the  lamp  and  it,  with  the  steam  from  a  vessel  of  water  also  placed  over  the 
lamp,  is  absorbed  by  the  patient's  skin.  This  treatment  affects  favorably 
both  the  constitutional  symptoms  and  the  eruption.  Calomel  vapor 
when  inhaled,  the  mouth  being  held  about  20  inches  from  the  containing 
vessel,  often  exerts  a  favorable  influence  upon  the  mucous  patches.    After 


SYPHILIS. 


153 


the  inhalation  the  mouth  should  be  thoroughly  washed  to  prevent  salivation. 

Hutchinson  prefers  to  give  mercury  with  chalk  {hydrargyrum  cum  creta) 
in  pill  form,  each  pill  containing  i  grain  (0.065)  each  of  this  preparation  and 
Dover's  powder;  one  pill  to  be  taken  from  4  to  6  times  a  day.  Most  excellent 
results  are  said  to  be  obtainable  from  this  form  of  treatment. 

While  undergoing  mercurial  treatment  the  patient  should  be  forbidden 
to  eat  fruit  and  green  vegetables. 

Instances  are  often  met  in  which  greater  benefit  is  achieved  by  the  alternate 
administration  of  mercury  and  iodine  or  by  giving  these  drugs  in  combination, 
the  so-called  "mixed  treatment."  Those  in  which  this  form  of  treatment 
is  particularly  indicated  are  the  cases  with  dry  tubercular  syphilides,  cases 
with  the  syphilitic  rupia,  those  with  choroiditis,  onychia,  periostitis  and 
cerebral  syphilis.  The  following  formula  will  be  found  useful:  I^.  Hydrar- 
gyri  iodidi  rubri,  gr.  iii  (0.2);  potassii  iodidi,  5ii  ss  (lo.o);  syrupi  simplicis,  q. 
s.  ad,  3iv  (120.0).    Misce  et  signa,  one  teaspoonful  two  or  three  times  daily. 

The  potassium  iodide  in  this  formula  may  be  increased  as  indicated. 
Another  useful  prescription  is  composed  of  mercury  bichloride  two  grains 
(0.13),  potassium  iodide  three  to  five  drachms  (12.0  to  20.0)  and  distilled  water 
and  compound  syrup  of  sarsaparilla  equal  parts  up  to  four  ounces  (120.0). 
Here  the  combination  of  potassium  iodide  with  mercury  bichloride  results 
in  the  production  of  a  certain  amount  of  red  mercuric  iodide  which  is  dis- 
solved in  the  excess  of  potassium  iodide.  The  mixed  form  of  treatment  has 
been  considered  especially  effective  in  the  intermediate  period  of  the  disease 
when  the  secondary  stage  is  passing  into  the  tertiary.  It  is  also  indicated  in 
instances  of  syphilitic  hepatitis  and  in  the  presence  of  the  ascites  of  this  con- 
dition the  so-called  Guy's  diuretic  pill  which  is  composed  of  i  grain  (0.065) 
each  of  powdered  digitalis,  squill  and  calomel  may  be  prescribed  with  benefit. 

In  the  third  stage  of  syphiUs  iodine,  administered  in  the  form  of  the  iodides 
and  particularly  potassium  iodide,  produces  results  which  cannot  be  accom- 
plished by  any  other  means,  the  rapid  absorption  of  nodes,  gummata 
and  other  deposits  quite  frequently  being  brought  about.  In  order  to 
secure  the  best  effect  it  is  necessary  to  give  very  large  amounts  in  many 
instances,  two  to  four  drachms  (8.0  to  16.0)  being  not  an  unusually  large 
daily  dosage.  In  syphilis  of  the  nervous  system  especially  large  doses  are 
called  for  and  daily  amounts  of  i  ounce  (30.0)  are  not  infrequently  required. 
The  drug  may  be  administered  in  saturated  aqueous  solution,  in  milk  or  in 
the  compound  syrup  of  sarsaparilla  beginning  with  10  drops  (0.66)  three  times 
a  day  and  increasing  the  doses  i  drop  (0.065)  daily  until  the  disease  is  con- 
trolled. Should  the  symptoms  of  iodism  appear — nasal  discharge,  an  erythem- 
atous eruption,  increased  secretion  of  saliva  and  swelling  of  the  salivary 
glands  causing  a  sense  of  tightness  in  the  throat — the  drug  should  be  stopped 
or  the  dose  diminished  until  these  disappear.     It  has  been  advised  to  enlarge 


154  THE    INFECTIOUS    DISEASES. 

the  beginning  dose  to  30  to  40  minims  (2.0  to  2.66),  since,  when  given  in  this 
way,  the  drug  has  seemed  less  likely  to  cause  toxic  symptoms.  Another 
most  excellent  method  of  giving  iodine  is  in  the  form  of  the  syrup  of  hydriodic 
acid.  The  dosage  of  this  preparation  is  from  i  to  4  drachms  (4.0  to  16.0) 
three  times  a  day  J  hour  before  meals  and  diluted  with  a  wine  glass  of  water. 
Iodine  itself  may  be  administered  in  capsules  each  containing  from  10  to  20 
drops  (0.66  to  1.33)  of  a  10  percent,  solution  of  resiiblimed  iodine  in  oil  of 
sesamum.  Strontium  and  sodium  iodide  have  been  suggested  as  substi- 
tutes for  the  potassium  salt  since  they,  especially  the  former,  are  pleasanter 
to  take,  are  less  likely  to  disturb  the  stomach  and  to  cause  toxis  symptoms. 

It  is  said  that  the  iodide  should  be  suspended  during  menstruation  if  there 
is  any  tendency  to  menorrhagia. 

During  a  course  of  antisyphilitic  treatment  the  patient  should  be  advised 
to  regulate  his  mode  of  life  in  accordance  with  strict  hygienic  principles; 
fresh  air,  moderate  exercise  and  nutritious  diet  are  essentials.  The  elimina- 
tory  functions  should  be  kept  properly  active  and  co-existent  disease,  especi- 
ally tuberculosis  or  anremia,  should  receive  appropriate  tonic  treatment. 

The  treatment  of  syphilis  at  mineral — especially  sulphur — springs  has  no 
advantage  over  a  thoroughly  carried  out  home  treatment.  At  such  places 
it  is  perhaps  easier  for  the  patient  to  lead  a  regular  and  healthful  life  and  the 
frequent  employment  of  baths  may  render  the  skin  more  receptive  to  inunc- 
tions of  mercury. 

The  treatment  of  hereditary  syphilis  should  be  instituted  as  soon  as  the 
symptoms  of  the  disease  appear  or  even  sooner  if  the  parents  give  distinct 
evidence  of  the  disease.  Mercury  and  potassium  iodide  are  as  potent  here 
as  in  adults  and  may  be  administered  in  the  same  way.  Usually  the  inunction 
method  is  preferable.  The  technique  of  the  treatment  has  been  already 
described  and  about  20  grains  (1.33)  of  a  mixture  of  equal  parts  of  mercurial 
ointment  and  lanolin  or  vaseline  are  employed  at  each  friction.  For  a  child 
of  two  years  30  grains  (2.0)  may  be  used  and  at  three  years  of  age  the  dose 
may  be  increased  to  40  grains  (2.66).  The  inunctions  should  be  continued 
for  three  weeks,  suspended  for  a  week  or  ten  days  and  then  repeated.  The 
internal  administration  of  mercury  should  then  be  begun.  Either  mercury 
with  chalk  i  grain  (0.065)  or  mercury  bichloride  g^^  of  a  grain  (0.00 1) 
four  times  a  day  may  be  given  unless  it  is  desirable  to  mercurialize  the  patient 
as  quickly  as  possible  when  y^  of  a  grain  (0.006)  of  calomel  should  be 
given  three  or  four  times  daily.  Mercury  should  be  continued  for  a  year, 
with  occasional  intermissions  of  a  week  or  more,  at  the  end  of  which  period, 
mixed  treatment  may  be  prescribed.  Here  we  may  give  a  mixture  con- 
sisting of  yV  Pa-^t  of  mercury  biniodide,  5  parts  of  potassium  iodide,  simple 
syrup  250  parts;  this  may  be  given  in  milk  in  the  following  doses.  To  a 
child  of  from  i  to  3  years,  15  to  30  minims  (i.o  to  2.0);  3  to  5  years,  i 


TUBERCULOSIS.  1 55 

drachm  (4.0);  6  to  10  years,  2  drachms  (8.0).  The  treatment  by  hypo- 
dermatic injections  may  be  employed  in  instances  of  digestive  disturbance 
and  where  the  mercurial  frictions  irritate  the  skin. 

In  tertiary  infantile  syphilis  with  gummata,  visceral,  osseous  and  other 
lesions,  potassium  iodide  should  be  prescribed  in  sufficient  dose  to  meet  the 
indication.  The  daily  dosage  for  a  child  of  from  i  to  15  months  is  from  | 
to  3  grains  (0.048  to  0.2),  from  15  months  to  3  years,  3  to  6  grains  (0.2  to 
0.4),  from  3  to  5  years,  yj  to  15  grains  (0.5  to  i.o)  and  from  5  to  10  years, 
15  to  45  grains  (i.o  to  3.0J.  The  drug  should  be  given  well  diluted  with 
milk  and  if  it  is  not  well  borne  the  substitutes  suggested  on  p.  154  may  be 
employed. 

Antisyphilitic  treatment  should  be  continued  as  long  as  luetic  manifesta- 
tions are  present. 

The  local  treatment  of  infantile  syphilis  is  identical  with  that  of  the  disease 
in  adults  and  it  is  often  of  great  advantage,  particularly  if  the  child's  nutrition 
is  poor  and  anaemia  is  present,  to  either  intermit  the  specific  treatment  for  a 
time  or  to  diminish  the  dosage,  in  the  meantime  giving  various  tonics,  partic- 
ularly iron,  codliver  oil  and  the  bitters. 

Attempts  have  been  made  to  elaborate  a  serum  for  the  treatment  of  syphilis 
but  up  to  the  present  time  little  or  no  success  has  attended  these  efforts. 

TUBERCULOSIS. 

Definition.  Tuberculosis  is  an  infectious  disease  characterized  by  gen- 
eral or  local  inflammatory  processes  resulting  from  the  presence  and  growth 
within  the  organism  of  the  tubercle  bacillus.  The  typical  lesions  consist 
of  nodules  or  diffuse  tissue  infiltrations  which  gradually  become  caseous, 
sclerosed,  ulcerated  or,  more  rarely,  undergo  calcification. 

.Etiology. — While  tuberculosis  was  considered  a  disease  of  infectious 
character  previous  to  Koch's  demonstration  of  the  bacillus  tuberculosis  in 
1882,  it  remained  for  this  observer  to  prove  beyond  question  its  specific  origin. 
Koch's  bacillus  is  a  long,  narrow,  straight  or  slightly  curved  bacillus,  staining 
at  times  irregularly  so  as  to  present  a  beaded  appearance.  It  is  found  in 
tuberculous  lesions  and  discharges  and  in  the  dust  of  apartments  occupied 
by  affected  patients  as  a  result  of  the  drying  of  unproperly  cared  for  sputum. 
It  is  also  found  in  the  meat  and  milk  of  diseased  animals,  those  most  fre- 
quently harboring  the  infection  being  the  bovines;  it  is  rare  in  sheep  and  horses 
but  pigs  in  certain  districts  are  prone  to  suffer.  Tuberculosis  is  very  likely 
to  attack  apes  in  captivity  but  is  unknown  amongst  them  in  the  wild  state. 

The  bacillus  effects  entrance  into  the  body  in  most  instances  upon  the 
inspired  air  which  may  be  contaminated  by  dried  sputum  or  may  contain 
the  moist  particles  which  are  emitted  by  tuberculous  individuals  in  coughing. 


156  THE  INFECTIOUS  DISEASES, 

sneezing  and  even  during  conversation.  These  fine  bits  of  spray  have  been 
proven  to  contain  the  bacilli.  These  facts  account  for  the  frequency  with 
which  those  closely  associated  with  subjects  of  the  disease,  such  as  nurses, 
members  of  the  family,  etc.,  contract  the  disease,  although  there  is  no  doubt 
that  by  careful  attention  to  cleanliness  and  proper  hygiene  this  danger  can 
be  almost  wholly  averted. 

The  contagium  may  also  be  taken  into  the  alimentary  tract  with  the  food, 
instances  having  been  traced  to  the  milk,  meat  and  even  the  butter  from 
infected  animals.  Food  may  become  contaminated  by  proximity  to  tuber- 
culous cooks,  bakers,  etc.,  and  the  milk  from  a  diseased  mother  may  infect 
her  infant,  accounting  for  the  occurrence  of  tuberculosis  of  the  digestive  tract 
in  children. 

Contact  with  the  excreta  of  the  tuberculous,  with  the  meat  of  diseased 
animals,  with  the  lesions  of  bodies  dead  from  the  infection,  etc.,  may  cause 
tuberculosis  by  inoculation.  To  the  acquirement  of  the  disease  in  this  way 
the  contact  of  the  infective  matter  with  an  abrasion  of  the  skin  or  mucous 
membrane  is  necessary. 

With  regard  to  the  hereditary  transmission  of  tuberculosis  it  may  be  said 
that  the  disease  has  been  noted  in  rare  instances  in  the  foetus  and  that  infants 
have  been  born  with  tuberculous  lesions;  this  circumstance  also  has  been 
observed  but  seldom.  It  is  a  fact  that  the  children  of  tuberculous  parents 
are  more  prone  to  the  acquirement  of  the  disease  and  possess  poorer  powers 
of  resistance  than  do  those  of  more  healthy  heredity. 

Other  predisposing  causes  are: 

a.  Race.  The  disease  is  met  in  all  races,  the  negro  and  the  American 
Indian,  living  under  civilized  conditions,  being  especially  prone  to  the  affec- 
tion. Hebrews  seem  to  a  certain  degree  exempt,  perhaps  owing  to  the 
peculiar  supervision  exercised  over  the  meat  consumed  by  them. 

h.  Age.  Tuberculosis  may  occur  at  any  time  of  life  but  certain  types 
seem  more  common  at  certain  ages  than  at  others,  thus  pulmonary  tubercu- 
losis is  most  frequent  between  20  and  35  while  children  are  particularly  prone 
to  the  glandular,  meningeal  and  mesenteric  forms. 

c.  Sex.  Females  appear  to  be  slightly  more  susceptible  than  males,  per- 
haps because  their  duties  confine  them  to  the  house  more  than  do  those  of 
the  opposite  sex.  The  progress  of  the  disease  becomes  more  rapid  during 
pregnancy  and  lactation. 

d.  Climate.  Regions  which  are  subject  to  dampness  and  sudden  changes 
of  temperature  are  most  favorable  to  the  development  of  tuberculosis,  possibly 
because  under  such  conditions  catarrhal  affections  are  common,  these  dimin- 
ishing the  resisting  power  of  the  body  and  offering  an  acceptable  nidus  for 
lodgment  of  the  contagium.     The  disease,  however,  does  occur  in  all  climates. 

e.  Sanitation.     Unhealthful  surroundings,  overcrowding,  lack  of  fresh  air, 


TUBERCULOSIS.  1 57 

and  of  proper  food,  and  unhygienic  occupations,  such  as  those  which  entail 
the  respiration  of  dust-laden  atmosphere,  are  distinct  predisposing  factors. 

Further,  any  acute  or  chronic  disease,  particularly  catarrhal  affections  of  the 
respiratory  tract,  influences  which  bring  about  a  diminished  pulmonary 
blood  supply,  congenital  or  acquired  narrowing  of  the  pulmonary  artery 
and  other  circulatory  diseases,  predisposes  to  the  occurrence  of  tuberculous 
affections.  Traumatisms  of  the  thorax,  although  there  may  be  no  injury 
to  the  lung  itself,  also  may  be  followed  by  pulmonary  tuberculosis. 

Pathology.  The  characteristic  morbid  change  is  the  occurrence  in  various 
tissues  and  organs  of  miliary  tubercules.  The  most  frequent  sites  for  their 
development  are  the  lungs,  liver  and  spleen;  they  are  also  found  in  the 
meninges,  the  bone-marrow,  the  peritonaeum,  the  heart  muscle  and  the 
choroid.  The  tubercles  vary  from  microscopic  size  to  that  of  a  pea  and  histo- 
logically are  made  up  of  a  number  (from  lo  to  50)  of  smaller  tubercles.  The 
fact  that  many  of  them  resemble  in  size  and  form  a  millet  seed  has  led  to  the 
term  miliary.  The  tubercle  is  formed  as  follows:  The  bacilli  having  lodged 
in  a  certain  tissue  act  as  an  irritant,  as  a  result  of  which  there  is  an  emigration 
of  leucocytes  from  the  neighboring  blood-vessels;  these,  with  the  epithelioid 
and  giant  cells,  which  are  produced  by  proliferation  from  the  cells  of  the  adja- 
cent structures,  and  with  a  supporting  frame-work  of  connective  tissue,  which 
is  most  abundant  near  the  periphery,  make  up  the  miliary  nodule.  The 
bacilli  occur  within  the  substance  of  the  epithelioid  cells  and  the  giant  cells 
and  the  fact  has  been  noted  that  where  the  latter  are  most  plentiful  the 
bacilli  are  fewest;  accordingly,  in  lupus,  tuberculous  joint  lesions  and  adenitis 
the  giant  cells  are  many  and  the  bacilli  few,  while  in  pulmonary  lesions  the 
opposite  condition  obtains. 

The  tubercle  also  occurs  in  solitary  form;  here  it  is  not  composed  of  an 
aggregation  of  small  miliary  bodies  but  is  a  single  cheesy  mass  of  size  varying 
from  that  of  a  pea  to  that  of  the  fist.  It  consists  principally  of  round  cells 
in  which  the  bacilli  are  found;  these  are  supported  by  a  fibrous  reticulum  and 
the  latter  may  exist  in  such  amount  as  to  render  the  entire  nodule  fibrous 
in  consistency.  These  single  tubercles  are  found  in  different  situations  such 
as  the  spinal  cord,  the  liver,  the  heart,  the  spleen  and  especially  in  the  brain 
in  children  and  are  subject  to  caseous,  suppurative  and  calcareous  degen- 
eration. 

The  Degenerations  of  Tubercle.  Of  these  the  most  common  is  caseation. 
This  begins  at  the  center  of  the  tubercle  and  is  a  process  of  coagulation  necrosis 
of  its  cells;  these  gradually  lose  their  outline,  their  nuclei  become  indistinct 
and  are  no  longer  demon?trable  by  staining  and  finally  a  structureless  granu- 
lar mass  results.  The  bacilli  persist  and  the  cheesy  substance  resulting  may 
undergo  softening,  calcification  or  may  become  encapsulated  by  a  fibrous 
wall.     The  first  of  these  processes  is  the  most  frequent  and  the  caseous  mass 


158  THE    INFECTIOUS    DISEASES. 

degenerates  into  a  puriform  substance  which  is  not  pus,  strictly  speaking,  but 
which  consists  of  fat  droplets,  granular  matter  and  disintegrated  cells,  and 
contains  tubercle  bacilli  in  abundance. 

Calcification  is  less  common;  here  a  form  of  healing  takes  place  by  infil- 
tration of  the  tubercle  with  calcium  salts.  Tuberculous  deposits  in  the  lymph 
glands  are  particularly  likely  to  undergo  this  change  and,  exceptionally,  it 
may  occur  in  the  lungs. 

The  sclerotic  change  in  which  the  tubercle  is  converted  into  fibrous  tissue 
consists  of  a  metamorphosis,  which,  as  the  disintegration  at  the  center  of 
the  nodule  takes  place,  is  characterized  by  hyaline  degeneration  and  increase 
of  fibroid  tissue,  a  firm  hard  mass  resulting;  this  is  a  healing  process  and 
depends  upon  the  body's  power  of  resistance  to  the  growth  and  development 
of  the  bacilli.  It  is  frequently  observed  in  peritonaeal  tuberculosis  and  at 
times  is  seen  in  the  lungs. 

Secondary  inflammatory  processes  are  changes,  set  up,  not  in  the  tubercle 
itself,  but  in  adjacent  tissues  by  the  development  of  this  structure;  for  instance 
an  overgrowth  of  connective  tissue  may  result  causing  a  fibroid  phthisis 
or  a  catarrhal  pneumonia.  Suppuration  is  a  frequent  associate  of  tuber- 
culous pulmonary  inflammation  but  is  the  result  of  a  mixed  infection  with 
pyogenic  bacteria.  Whether  the  tubercle  bacillus  is  capable  alone  of  produc- 
ing pus  is  a  moot  question.  Certainly  the  fluid  contents  of  a  cold  abscess 
is  not  true  pus  and  does  not  contain  the  bacteria  of  suppuration.  On  the 
other  hand,  in  tuberculous  inflammations  of  bones  and  joints,  pus  is  often 
observed;  this,  however,  may  be  the  result  of  mixed  infection  just  as  is  the 
purulent  sputum  of  pulmonary  tuberculosis. 

Acute  Miliary  Tuberculosis. 

Synonym.     Diffuse  General  Tuberculosis. 

Definition.  An  acute  disease  characterized  by  the  presence  of  numbers 
of  tubercle  bacilli  in  the  blood  which  find  lodgment  in  various  parts  of  the 
body  and  there  cause  the  development  of  miliary  tubercles.  The  disease  is, 
as  a  rule,  secondary  to  the  softening  of  a  tuberculous  nodule,  usually  in  the 
lungs  or  a  lymph  gland,  and  is  the  result  of  the  dissemination  of  the  bacilli 
by  means  of  the  blood  or  lymph  circulation.  The  rupture  of  the  nodule  may 
be  directly  into  a  blood-vessel,  an  example  of  a  veritable  embolic  process. 

This  form  of  tuberculosis  is  most  common  in  adolescents  and  young  adults. 

Pathology.  In  considering  acute  miliary  tuberculosis  from  its  pathologic 
aspect  it  is  not  to  be  forgotten  that  it  is  the  result  of  an  old  tuberculous  lesion. 
The  tubercles  which  are  disseminated  through  the  various  tissues  in  this  form 
of  tuberculosis  have  already  been  described  (p.  157). 

Acute    tuberculosis    occurs,  in  three  principal  types:     i.   With  symptoms 


TUBERCULOSIS.  1 59 

pointing  to  general  infection.  2.  General  infection  with  pronounced  pulmo- 
nary symptoms.  3.  General  infection  with  marked  symptoms  referable  to  the 
central  nervous  system. 

I.  Acute  General  Miliary  Tuberculosis. 

Symptoms.  These  are  those  of  a  severe  general  infection  without  marked 
local  manifestations  and  there  is  great  possibility  of  mistaking  the  disease 
for  enteric  fever.  Prodromata,  consisting  of  indefinite  malaise,  loss  of  ap- 
petite, etc.,  are  common  but  an  abrupt  onset  with  fever  may  occur;  afebrile 
instances  of  the  disease  have  occasionally  been  observed.  The  pulse  is  rapid, 
the  tongue  dry  and  cerebral  symptoms  analogous  to  those  of  enteric  fever 
are  common.  The  temperatiue  is  usually  lower  in  the  morning  (101°  F. — 
38.3°  C.)  and  higher  at  night  (103°  to  105°  F. — 39.4°  to  40.5°  C.),  although  an 
occasional  reversal  of  this  type  of  temperature  may  occur;  this  is  considered  an 
important  point  in  the  differentiation  of  the  disease,  as  is  also  the  fact  that 
the  temperature  curve,  taken  as  a  whole,  is  more  irregular  than  that  of  enteric 
fever  and  does  not  present  the  progressive  rise  of  that  afifection.  Bronchitis 
may  be  present  but  may  not  be  more  pronounced  than  that  occurring  in 
typhoid  infection.  Profuse  sweating  is  common  and  herpes  may  be  observed; 
splenic  enlargement  may  be  noted  and  spots  resembling  those  of  typhoid 
fever  have  been  described.  The  latter,  however,  do  not  appear  in  successive 
crops. 

Early  in  the  disease  there  are  seldom  physical  signs  referable  to  the  lungs 
other  than  those  of  a  slight  bronchitis,  later  the  respiration  may  be  accelerated 
and  slight  cyanosis  may  occur.  As  the  disease  progresses  pulmonary  and 
meningeal  manifestations  may  appear.  There  may  also  be  signs  and  symp- 
toms of  pleuritic,  pericardial  or  peritonaeal  involvement.  Tuberculosis  of  the 
choroid  may  also  be  noted. 

The  diagnosis  is  often  difficult,  the  disease  being  especially  likely  to  be 
confounded  with  enteric  fever  from  which  it  may  be  differentiated  by  its 
temperature  curve,  its  duration,  which  is  more  protracted,  the  splenic  enlarge- 
ment which  appears  later  and  is  less  pronounced,  and  by  the  lack  of  rose- 
spots.  Cyanosis  and  accelerated  respiration  are  more  frequent  in  tuber- 
culosis. 

In  neither  disease  are  the  leucocytes  increased  in  number,  but  upon  the 
incidence  of  mixed  infection,  which  sooner  or  later  may  manifest  itself  in 
tuberculous  infection,  a  leucocytosis  appears.  The  examination  of  the 
sputum  rarely  reveals  the  presence  of  tubercle  bacilli  unless  the  pulmonary 
nodules  disintegrate  through  the  bronchial  mucous  membrane;  they  are, 
however,  to  be  found  in  the  blood,  especially  that  withdrawn  from  the  spleen. 
When  not  directly  demonstrable,  culture  and  inoculation  experiments  may 
reveal  their  presence. 


l6o  THE    INFECTIOUS    DISEASES. 

The  absence  of  the  Widal  reaction  is  a  valuable  point  in  differentiation. 

The  urine  may  contain  albumin,  usually  not  as  a  result  of  tuberculous 
kidney  involvement,  but  of  the  febrile  process.  Unfortunately  the  Ehrlich 
diazo-reaction  is  often  present  in  acute  tuberculosis  as  well  as  in  enteric  fever. 

The  cerebrospinal  fluid,  withdrawn  by  lumbar  puncture,  may  contain 
tubercle  bacilli  even  though  meningeal  inflammation  is  not  a  feature  of  the 
patient  in  hand. 

The  prognosis  of  this,  as  well  as  of  other  forms  of  acute  tuberculosis,  is 
distinctly  unfavorable,  a  fatal  outcome  being  almost  inevitable.  The  course 
of  the  infection  is  usually  from  four  to  eight  weeks  or  more,  although  more 
rapidly  fatal  instances  have  been  observed. 

Treatment  is  wholly  symptomatic  and  consists  in  the  administration  of 
proper  nourishing  food  in  sufficient  quantity,  of  stimulants  as  indicated,  of 
antipyretics,  such  as  antipyrine  or  acetphenetidine — five  grains  (0.33)  re- 
peated as  necessary — of  sedatives,  such  as  the  bromides,  to  quiet  the  nervous 
symptoms  and  of  such  drugs  as  heroine  or  codeine  to  allay  the  cough.  The 
skin,  kidneys  and  bowels  should  be  kept  properly  active  by  means  of  the 
usual  measures. 

2.  Acute  General  Tuberculosis  of  Pulmonary  Form. 

Symptoms.  This  type  of  the  disease  occurs  in  adults  who  have  been  the 
subjects  of  chronic  bronchitis  or  of  chronic  tuberculosis  and  is  often  observed 
in  children  after  measles  or  whooping  cough.  The  symptoms  are  those 
of  a  marked  acute  bronchitis;  with  the  cough  there  is  muco-purulent  expec- 
toration; haemoptysis  is  rare.  Dyspnoea  and  cyanosis  are  pronounced;  the 
pulse  is  rapid  and  feeble,  the  temperature  irregular,  rising  at  night  to  102° 
to  103°  F.  (38.9°  to  39.4°  C.)  or,  perhaps,  elevated  in  the  morning  and  low 
in  the  evening.  The  spleen  is  increased  in  size  in  infections  of  acute  course. 
The  outcome  is  invariably  fatal,  death  occurring  at  times  within  two  weeks. 
In  other  instances  the  disease  may  progress  for  several  months. 

The  physical  signs  are  those  of  bronchitis  (sibilant  and  sonorous  rales), 
or  there  may  be  areas  of  diminished  resonance  with  bronchial  or  broncho- 
vesicular  breathing  and  fine  crepitant  rales  due  to  scattered  foci  of  broncho- 
pneumonia. Areas  over  which  the  note  is  hyper-resonant,  as  a  result  of 
localized  emphysema,  may  be  evident.  As  the  disease  progresses  the  rales 
become  louder  and  more  moist.  Tuberculous  involvement  of  the  pleura 
gives  rise  to  friction  rales. 

The  diagnosis  is  to  be  made  upon  the  points  already  set  down  on  p.  159. 
The  presence  of  marked  dyspnoea  and  cyanosis  with  the  signs  of  bronchitis 
is  always  suspicious.  The  choroid  should  be  inspected  for  the  presence  of 
tubercles  and  the  sputum  examined  for  the  bacilli,  which  are  by  no  means 


TUBERCULOSIS.  l6l 

always  present.     A  history  of  lymphoid  enlargement  or  of  measles  or  pertussis 
will  often  aid  in  the  diagnosis. 

Treatment  is  likely  to  prove  useless  but  the  patient  should  be  made  as 
comfortable  as  possible  and  the  symptoms  should  be  relieved  as  they  arise; 
otherwise  the  treatment  is  identical  with  that  of  chronic  pulmonary  tuber- 
culosis. 

3.  Acute  General  Tuberculosis  of  Meningeal  Form.     See  Tuberculous 

Meningitis,  p.  729. 

Pulmonary  Tuberculosis. 
Acute  Pneumonic  Pulmonary  Tuberculosis. 

Synonyms.     Phthisis  Florida;  Galloping  Consumption. 

This  type  of  pulmonary  tuberculosis  occurs  in  two  forms,  the  pneumonic 
and  the  broncho-pneumonic.  In  the  former  one  lobe  or  an  entire  lung  may 
be  affected  and  its  condition  resembles  that  found  in  acute  lobar  pneumonia. 
The  pleura  is  the  seat  of  an  exudative  inflammation  and  is  filled  with  cheesy 
matter  composed  of  aggregations  of  tubercles,  which  if  the  disease  lasts  long 
enough,  soften,  and  cavity  formation,  especially  at  the  apices,  takes  place. 
In  the  broncho-pneumonic  type  the  consolidation  takes  place  in  scattered 
areas,  as  a  result  of  which  there  are  disseminated  foci  of  whitish  cheesy  matter 
which  are  separated  from  one  another  by  congested  pulmonary  tissue.  These 
foci  tend  to  soften  and  become  tiny  abscesses.  The  bronchial  lymph  glands 
are  usually  the  seat  of   tuberctilous  inflammation. 

Symptoms.  The  pneumonic  type  is  more  common  in  adults.  Its  onset 
is  marked  by  a  chill  followed  by  rise  in  temperature,  cough  with  mucoid, 
often  blood  stained,  sputum,  pain  in  the  side  and  dyspnoea.  The  affection 
is  often  mistaken  for  an  acute  lobar  pneumonia  which  it  resembles  markedly 
in  its  early  symptoms  and  physical  signs,  which  are  those  of  pulmonary  con- 
solidation occurring  in  one  or  more  lobes.  Resolution,  however,  does  not  take 
place  but,  as  the  consolidation  softens,  the  physical  signs  of  a  cavity  become 
manifest  and  microscopic  examination  of  the  sputum  reveals  tubercle  bacilli. 
The  course  of  this  type  of  the  disease  is  usually  from  one  to  three  months, 
when  death  may  take  place  or  the  process  may  become  a  chronic  pulmonary 
tuberculosis.     A  rapid  course  is  rare. 

The  broncho-pneumonic  type  is  most  often  met  in  children  in  whom  it  is 
prone  to  follow  measles  or  pertussis.  The  child  is  affected  with  a  chronic 
bronchitis  with  fever,  cough  and  dyspnoea;  the  signs  are  those  of  bronchitis, 
moist  and  subcrepitant  rales  being  abundant  and  small  areas  of  consolidation, 
evidenced  by  a  high  pitched  percussion  note,  broncho-vesicular  voice  and 
breathing  may  be  demonstrated.      Emaciation  is  rapid,  the  temperature  be- 


l62  THE    INFECTIOUS    DISEASES.     ' 

comes  of  hectic  type  and,  as  the  areas  of  consolidation  soften,  tubercle  bacilli 
appear  in  the  sputum.  The  prognosis  is  bad,  death  usually  ensuing  within 
one  to  two  months;  more  rare  are  the  patients  in  whom  the  disease  is 
rapidly  fatal  and  those  who  go  on  to  chronic  pulmonary  tuberculosis. 

Treatment  during  the  acute  stage  consists  in  maintaining  the  patient's 
nutrition  and  combating  the  symptoms  as  they  arise.  That  of  the  chronic 
stage  will  be  considered  later  under  the  treatment  of  chronic  pulmonary 
tuberculosis. 

Chronic  Pulmonary  Tuberculosis. 

I.  Chronic  Ulcerative  Phthisis. 

This  is  the  most  common  form  of  pulmonary  tuberculosis  and  begins  with  the 
formation  of  miliary  tubercles  in  various  parts  of  the  lung,  usually,  however, 
in  the  apices.  At  its  inception  it  is  a  purely  tuberculous  disease  and  so  remains 
until  the  softening  and  breaking  down  of  the  tubercles,  when  the  resulting 
ulcerating  surfaces  become  infected  with  the  bacteria  of  suppuration  and  a 
so-called  "mixed  infection"  results. 

Pathology.  The  morbid  changes 'present  in  the  lung  of  chronic  ulcerative 
phthisis  are  many  and  varied.  The  disease  spreads  from  the  initial  point 
of  infection  which  is  ususilly  a  little  below  the  apex  of  one  or  the  other  lung 
and  often  nearer  the  posterior  than  the  anterior  aspect.  Consequently  the 
situation  at  which  physical  signs  are  first  perceptible  is  either  on  the  anterior 
surface  of  the  chest  just  below  the  middle  of  the  clavicle  or  posteriorly  in  the 
supra-spinous  fossa.  From  this  spot  the  process  spreads  downward,  affecting 
the  outer  portion  of  the  upper  lobe  rather  than  the  inner.  Later  the  apex 
of  the  other  lung  becomes  involved  but  usually  not  before  the  disease  has 
affected  the  upper  part  of  the  lower  lobe  of  the  lung  first  attacked.  Primary 
involvement  of  the  bases  of  the  lungs  is  rare. 

The  lesions  found  in  the  tuberculous  lung  are  by  no  means  constant  nor  do 
all  the  conditions  to  be  described  necessarily  obtain  in  every  patient.  The 
morbid  changes  which  may  occur  are  as  follows: 

a.  Miliary  tubercles.  These  vary  in  situation  depending  upon  whether 
the  infection  was  the  result  of  inhalation  or  of  dissemination  of  the  bacilli 
by  the  lymph  circulation.  In  the  former  instance  they  are  found  in  the  walls 
of  the  smaller  bronchi  or  air  spaces,  in  the  latter  they  occur  about  the  pri- 
mary foci  of  the  inflammation.  They  also  may  be  seen  in  the  walls  of  the 
small  blood-vessels. 

b.  Tuberculous  broncho-pneumonia.  Here  we  find  areas  of  caseation  due 
to  the  accumulation  in  and  around  the  small  bronchi  of  inflammatory  prod- 
ucts. These  foci  tend  to  coalesce  and,  if  rapid  degeneration  and  softening 
takes  place,  break  down  and  result  in  the  formation  of  small  cavities.  If  the 
process  is  more  chronic,  fibrous  tissue  may  develop  about  the  cheesy  mass 


TUBERCULOSIS.  1 63 

finally  encapsulating  it.  The  substance  within  this  fibrous  capsule  may 
either  remain  soft  and  caseous,  with  areas  of  calcareous  degeneration,  or 
become  entirely  sclerotic. 

c.  Tuberculous  pneumonia.  This  is  a  condition  characterized  by  an 
exudative  inflammation  involving  the  tissues  surrounding  the  tubercles. 
The  adjacent  alveoli  are  filled  with  epithelioid  cells.  Such  areas  of  consol- 
idation on  cut  section  resemble  the  red  hepatization  of  lobar  pneumonia  or 
yellowish  or  whitish  spots  may  be  observed  due  to  the  presence  of  foci  of 
fatty  degeneration. 

d.  Cavities,  the  result  of  the  breaking  down  of  the  tuberculous  areas,  are  a 
characteristic  anatomical  feature.  The  wall  of  the  bronchus  is  vitiated  by 
the  tuberculous  inflammation  and  ulceration,  is  strained  by  the  effort  of 
coughing,  yields,  and  finally  gives  way  forming  a  cavity  at  first  small  but 
later  of  larger  size,  since  adjacent  cavities  tend  to  unite  until  an  entire  lobe 
may  be  involved  in  the  process.  Fresh  cavities  possess  caseous  and  necrotic 
walls,  while  those  of  long  standing  are  lined  with  smooth  walls  of  granulation 
tissue  which  produce  pus.  Into  such  cavities  blood-vessels  of  considerable 
size  may  protrude  which  may  either  be  the  seat  of  an  obliterating  endarteritis 
or  of  aneurysmal  dilatations.  Such  vessels,  if  not  entirely  occluded  by  the 
arteritis,  when  eroded  by  the  inflammatory  process,  cause  haemorrhage.  The 
cavity  contains  the  pus  produced  by  its  lining,  tubercle  bacilli  and  other 
micro-organisms.  The  lung  about  the  cavity  may  be  consolidated.  Small 
cavities  often  have  ragged  and  necrotic  walls  which  continually  are  breaking 
down.  Cavities  may  also  result  from  the  softening  at  the  center  of  a  caseous 
mass  or  be  bronchiectatic  in  character.  Rupture  of  a  cavity  into  the  pleura 
with  consequent  pneumo-  or  pyo-pneumo-thorax,  may  take  place. 

e.  P/e/f my  accompanies  chronic  phthisis  in  the  great  majority  of  instances; 
it  may  be  either  simple  or  tuberculous,  in  which  case  mihary  tubercles  or  cheesy 
deposits  are  present.  There  may  be  thickening  of  the  pleura  with  adhesions, 
serous,  haemorrhagic  or  purulent  exudations,  or  a  condition  of  pyo-pneumo- 
thorax. 

/.  The  bronchial  lymph  nodes  usually  participate  in  the  infection.  In 
the  infections  of  rapid  onset  and  course  they  are  enlarged  and  softened  and 
contain  cheesy  areas  and  miliary  tubercles;  in  instances  of  more  protracted 
evolution  caseous  foci,  calcareous  degeneration  or  suppuration  may  be  ob- 
served. 

g.  Lesions  of  other  organs.  The  larynx  is  frequently  involved  even  to 
the  extent  of  destruction  of  the  epiglottis  and  vocal  cords.  The  cervical 
and  retro-peritonasal  glands  may  be  seat  of  tuberculous  inflammation  and  mili- 
ary tubercles  may  be  found  in  the  intestine,  the  spleen,  the  kidneys,  the  brain, 
the  liver  and  the  pericardium.  Tuberculous  endocarditis  may  be  observed. 
Especially  in  the  protracted  infections  we  may  find  amyloid  and  fatty  degen- 


164  THE   INFECTIOUS    DISEASES. 

erations  of  the  viscera.  The  former  occurs  in  the  liver,  kidneys,  spleen  and 
intestinal  lining  while  the  latter  is  more  prone  to  affect  the  liver  and  kidneys. 

Symptoms.  The  invasion  of  this  disease  is  most  insidious  and  conse- 
quently is  frequently  overlooked.  The  various  modes  of  onset  may  be  classi- 
fied as  follows: 

a.  With  successive  attacks  of  bronchitis,  each  more  obstinate  than  its 
predecessor.  The  patient  takes  cold  easily  and  finally  is  attacked  by  a  bron- 
chitis that  refuses  to  respond  to  treatment.  The  cough  becomes  frequent 
and  distressing  and  examination  reveals  the  presence  of  physical  signs. 

h.  With  symptoms  referable  to  the  stomach.  This  is  by  no  means  a  rare 
mode  of  invasion  but  is  often  overlooked  and  the  patient  is  sent  to  the  gas- 
trologist  who  exerts  himself  in  the  direction  of  his  specialty  while  the  patient 
loses  much  valuable  time.  Such  patients  complain  of  no  symptoms  pointing 
toward  the  lung  but  suffer  from  gastric  irritability,  eructations,  vomiting 
and  perhaps  hyperacidity.  An  accompanying  anaemia,  with  palpitation,  loss 
of  strength,  evening  rise  of  temperature  and  irregular  menstruation,  is  very 
frequent  in  young  women.  Too  much  stress  cannot  be  laid  upon  the  great 
importance  of  a  thorough  physical  examination  of  the  lungs  in  patients  present- 
ing such  symptoms. 

c.  The  onset  may  take  place  without  exciting  the  suspicion  of  the  patient 
to  the  fact  that  he  is  ill,  or  the  pulmonary  symptoms  may  be  masked  by  mani- 
festations due  to  affections  of  other  tissues,  such  as  the  peritonaeum,  intestinal 
tract  or  the  bones.  The  lungs  of  such  patients,  very  much  to  their  surprise, 
may  be  found  to  be  the  seat  of  advanced  tuberculous  disease. 

d.  An  onset  with  regularly  recurring  chills,  fever  and  sweating  may  occur 
in  which  the  manifestations  strongly  suggest  malarial  infection. 

e.  Pleurisy,  either  fibrinous  or  with  the  exudation  of  serum,  may  mark 
the  invasion  of  the  tuberculous  process,  signs  of  the'  latter  appearing  after 
the  former  conditions  have  been  present  for  longer  or  shorter  intervals. 

Certain  German  observers  have  considered  all  instances  of  serous  pleurisy 
to  be  of  tuberculous  origin  but  this  is  quite  too  sweeping  an  hypothesis.  Those 
from  which  blood-tinged  fluid  is  drawn  are  frequently  the  result  of  infection 
with  the  bacillus  of  Koch.  Bowditch  has  reported  90  instances  of  serous 
pleurisy  which  eventuated  in  pulmonary  phthisis. 

/.  Haemorrhage  from  the  lungs  appears  as  an  initial  symptom  in  a  certain 
number  of  patients  but,  in  these,  careful  questioning  may  elicit  a  history  of 
chronic  cough  or  hereditary  tuberculous  predisposition  showing  that  pul- 
monary involvement  has  pre-existed. 

g.  Laryngeal  symptoms,  especially  hoarseness,  as  initial  manifestations 
would  seem  to  argue  tuberculous  infection  of  the  larynx  as  a  primary  lesion 
to  which  those  of  the  lungs  are  secondary. 

h.  Pulmonary  tuberculosis  may  be  preceded  by  enlargement  of  the  glands 


TUBERCULOSIS.  1 65 

of  the  neck  or  axilla  and  examination  often  will  reveal  involvement  of  the 
lung  of  the  same  side. 

Of  the  symptoms  of  chronic  phthisis  cough  is  one  of  the  most  generally- 
present.  At  first  it  is  slight,  and  while  it  may  remain  so,  as  the  disease  pro- 
gresses, it  usually  increases  in  severity.  It  is  the  result  of  the  irritation 
caused  by  the  bronchitic  or  pneumonic  process  or  is  due  to  the  accumula- 
tion of  matter  in  the  tuberculous  cavities.  These  when  filled  are  often 
cleared  by  successive  fits  of  coughing.  Under  such  conditions  paroxysms 
of  coughing  occur  at  intervals.  The  expectoration  varies  with  the  ex- 
tent of  the  pulmonary  involvement.  At  first  it  is  scanty  and  mucoid, 
and  does  not  contain  the  bacilli;  this  is  during  the  so-called  pre-bacillary 
stage,  the  latter  being  a  misnomer  since  the  bacilli  are  present  within 
the  pulmonary  tissues  although  they  do  not  occur  in  the  bronchial  exu- 
date. After  ulceration  or  the  rupture  of  the  tuberculous  nodules,  bacilli  are 
present  and,  as  mixed  infection  usually  takes  place  at  this  time,  the  sputum 
also  contains  pus.  Blood  also  may  now  be  present  owing  to  the  involvement 
of  blood-vessels  by  the  process  of  ulceration  or  the  breaking  down  of  the 
tubercles.  In  quantity  the  sputum  varies  from  ^  an  ounce  (15.0)  to  eight 
ounces  (250.0)  during  24  hours.  It  is  seldom  foetid,  usually  possessing  a 
faint  sweetish  odor.  The  expectorations  often  take  a  circular  form  which  is 
termed  nummular  from  supposed  resemblance  to  a  coin.  Haemoptysis  occurs 
in  from  60  to  80  percent,  of  patients  and  is  a  result  of  the  rupture  of  vessels 
whose  walls  have  become  weakened  by  the  tuberculous  infiltration  or  of  the 
erosion  of  vessel  walls  by  the  inflammatory  process.  Early  in  the  disease 
the  quantity  of  blood  is  small  but  in  the  later  stages  it  may  be  so  large  as  to 
result  in  death.  Another  danger  of  haemoptysis  is  that  bits  of  clot  may  be 
drawn  deeper  into  the  lungs  by  respiration,  and,  acting  as  irritants,  cause 
inhalation  pneumonia.  Small  haemoptyses  early  in  the  disease  may  occur  as 
a  result  of  the  inflammation  of  the  bronchial  mucous  membrane. 

Microscopically  the  sputum  of  phthisis  may  contain  mucous,  epithelial 
cells  from  the  respiratory  tract  or  mouth,  bits  of  food,  Charcot-Leyden  crystals, 
red  blood-cells  and,  after  the  lung  tissue  has  begun  to  break  down  and  mixed 
infection  has  taken  place,  pus  cells,  tubercle  bacilli  and  elastic  tissue.  For 
the  technique  of  the  chemical  and  microscopical  examination  of  sputum  the 
reader  is  referred  to  any  reliable  work  upon  clinical  diagnosis. 

The  cough,  especially  late  in  the  disease,  often  incites  emesis,  probably  due 
to  the  irritation  of  the  pharynx  caused  in  the  act  of  coughing. 

Pain  is  not  a  typical  symptom  of  the  disease  but  may  be  caused  by  excessive 
coughing,  in  which  case  it  is  usually  in  the  lower  part  of  the  chest,  or  by  the 
pleurisy ;  here  it  is  sharp  and  stabbing  in  character  and  located  at  the  site 
of  the  pleural  inflammation,  although  at  times  it  may  be  referred  to  the  other 
side  of  the  thorax. 


1 66  THE    INFECTIOUS    DISEASES. 

Fever  is  a  very  constant  symptom.  Early  in  the  infection  it  is  the  result  of  the 
tuberculous  process  within  the  lungs  and  is  usually  slight  and  of  continued 
type  with,  perhaps,  slight  evening  exacerbations.  With  the  breaking  down 
of  the  tuberculous  tissue  in  the  lungs  and  the  incidence  of  mixed  infection, 
to  which  latter  it  is  due,  the  so-called  hectic  temperatiue  occurs.  This  is 
septic  both  in  origin  and  character,  usually  reaching  its  highest  point  during 
the  afternoon  or  evening  and  its  minimum  during  early  morning  hours. 
Certain  patients  may  exhibit  no  distinct  febrile  movement  during  their  entire 
course,  although  these  probably  have  had  fever  at  the  onset  of  the  infection. 
When  a  continuously  high  temperatvire,  lasting  from  a  day  to  a  week,  is  ob- 
served, it  is  usually  due  to  the  estabHshment  of  a  fresh  focus  of  broncho- 
pneumonia. 

With  the  hectic  temperature  there  are  usually  sweats.  These  are  the  result 
of  septic  infection  and  as  a  rule  occur  at  night — hence  the  term  "  night  sweats  " 
— although  they  may  appear  at  any  time. 

The  pulse  is  accelerated  even  early  in  the  disease  and  this  increase  in  its 
rate  is  often  an  important  point  in  the  diagnosis  of  incipient  tuberculosis. 

The  respirations  are  not  markedly  increased  in  number  even  with  con- 
siderable pulmonary  involvement.  Dyspnoea  may  occur  when  there  is  pneu- 
monic involvement,  when  there  is  serous  pleurisy  or  pneumo-thorax  and  in 
old  infections  with  emphysema  or  with  pleural  thickening  and  retraction  of 
the  thorax. 

Emaciation  is  progressive  and  is  a  pronounced  and  constant  symptom.  It 
is  a  dependable  index  of  the  evolution  of  the  disease. 

Late  in  the  disease  manifestations  due  to  involvement  of  other  organs  often 
occur.  Tuberculosis  of  the  intestine  is  evidenced  by  obstinate  diarrhoea. 
Meningeal  infection  causes  headache  and  other  cerebral  symptoms  (see 
p.  730).  Amyloid  and  fatty  degeneration  of  the  viscera  result  in  enlarge- 
ment of  the  organs  affected  and,  in  the  case  of  the  kidneys,  albuminuria. 
Tuberculosis  of  the  genito-iurinary  tract  with  pus  and  tubercle  bacilli  in  the 
urine  may  occur. 

Physical  Signs.  These  vary  with  the  stage  of  the  disease.  Careful  physical 
examination  of  the  chest  is  very  important  in  all  suspected  instances  and  the 
early  physical  signs,  i.e.,  those  present  in  the  incipient  or  pre-bacillary  stage, 
while  typical  and  easily  detected  by  the  acute  observer,  may  be  overlooked. 
These  are:  a.  Myoidema  of  the  chest  muscles.  This  phenomenon,  while 
not  characteristic  of  pulmonary  tuberculosis,  is  significant  of  a  hyper^sthetic 
condition  of  the  reflexes  and  is  likely  to  occiu:  as  a  result  of  any  disease  inter- 
fering with  nutrition,  h.  Upon  auscultation  of  the  heart  the  second  pul- 
monic sound  is  found  to  be  accentuated  owing  to  the  obstruction  to  the 
pulmonary  circulation  caused  by  the  inflammatory  process  in  the  lung.  c. 
The  cardiac  sounds  are  heard  at  the  apex  of  the  lung  as  a  result  of  trans- 


TUBERCULOSIS.  167 

mission  through  the  infiltrated  pulmonary  tissue,  d.  The  whispering  voice 
at  the  apex  or  just  below  the  clavicle  is  bronchial  in  character,  e.  A  blowing 
murmur  in  the  subclavian  or  the  pulmonary  artery  may  be  present.  Upon 
these  signs  the  diagnosis  can  be  made  even  before  distinct  dulness  upon 
percussion  or  the  presence  of  rales  can  be  detected. 

In  the  more  advanced  first  stage  of  the  disease  the  signs  are: 
a.  Inspection.  The  shape  of  the  chest,  while  not  characteristic,  is  often 
long  and  narrow  with  wide  intercostal  spaces  and  ribs  tending  toward  the 
vertical  in  direction.  The  scapulae  are  of  the  "winged"  t}^e.  The  thorax 
in  other  instances  may  be  flattened  antero-posteriorly  and  the  costal  cartilages 
are  prominent.  Depression  above  the  clavicle  and  retraction  below  are  impor- 
tant signs,  the  clavicle  being  more  prominent  than  normal.  The  body  may 
be  more  or  less  wasted,  the  respiration  may  be  slightly  accelerated  and  the 
pulse  rate  increased.  A  cardiac  apex  pulsating  over  an  increased  area  is 
suggestive  of  involvement  at  the  left  apex.  On  deep  inspiration  one  side  of 
the  thorax  will  often  expand  less  than  the  other;  especially  is  this  diminution 
of  expansion  noticeable  above  and  just  below  the  clavicle. 

h.  Mensuration  often  reveals  not  only  a  diminished  expansion  of  the 
affected  side  but  the  fact  that  this  half  of  the  chest  is  of  less  circumference 
than  the  other  while  at  rest. 

c.  Palpation  may  detect  the  presence  of  increased  fremitus  over  the  affected 
apex,  but  the  normal  exaggeration  of  the  fremitus  of  the  right  over  that  of 
the  left  apex  should  not  be  forgotten. 

d.  Percussion.  At  this  stage  the  note  above  or  just  below  the  clavicle  is 
usually  duller  than  normal. 

e.  Auscultation  reveals  an  increase  in  the  length  of  the  expiratory  murmur 
and  a  diminution  in  the  intensity  of  the  inspiratory  sound,  or  the  latter 
has  become  harsh  or  broncho-vesicular.  The  vocal  resonance  is  increased, 
the  whispered  bronchophony  referred  to  above  is  present  and  the  physical 
signs  of  a  more  or  less  generalized  bronchitis  are  usually  obtainable.  Crepi- 
tant and  subcrepitant  rales  at  the  apices  are  a  frequent  and  characteristic 
sign.  They  are  due  to  pleuritic  adhesions,  in  which  case  they  are  close  under 
the  ear,  occur  with  both  inspiration  and  expiration  and  are  increased  upon 
pressure  by  the  stethoscope,  or  to  bronchitis;  here  they  are  more  distinct, 
are  heard  at  the  end  of  inspiration  and  are  not  increased  on  pressure.  Cough- 
ing may  render  them  audible  when  they  cannot  be  detected  upon  respiration. 

In  the  second  stage  inspection  reveals  an  exaggeration  of  the  changes 
already  described,  the  emaciation  is  more  pronounced,  the  hectic  flush  may  be 
present  and  the  surface  temperature  may  be  heightened.  The  exaggerated 
vocal  fremitus  may  be  easily  detected  unless  a  thickened  pleura  prevents  its 
recognition.     The  percussion  note  is  now  distinctly  dull. 

Auscultation  reveals  an  increased  and  perhaps  a  broncho-vesicular  quality 


1 68  THE    INFECTIOUS    DISEASES. 

of  the  spoken  voice,  the  breathing  has  become  more  bronchial  in  character 
and  the  expiration  is  further  prolonged  and  is  blowing  in  quality.  Ultimately 
the  breathing  and  voice,  as  the  consolidation  becomes  more  pronounced  and 
of  greater  extent,  become  bronchial.  Rales  due  to  pleuritic  and  bronchial 
inflammation  are  also  present. 

The  signs  revealed  during  the  third  stage  by  inspection  are  those  of  the 
second  in  a  more  advanced  condition;  the  wasting  is  still  more  apparent,  the 
retraction  of  the  chest  is  more  marked,  the  respiratory  movement  more  re- 
stricted. The  surface  temperature  is  perceptibly  increased,  the  skin  may  be 
moist  if  sweating  is  present  and  the  vocal  fremitus  is  further  exaggerated. 
The  dulness  on  percussion  is  often  increased  to  flatness  and,  upon  the  occur- 
rence of  cavity  formation,  becomes  tympanitic,  amphoric  or  "cracked  pot"  in 
character,  if  the  lesion  is  near  the  surface.  The  note  may  be  unchanged  if 
the  cavity  is  small  and  deeply-seated.  Wintrich's  sign  is  pathognomonic; 
given  a  cavity  communicating  with  a  bronchus  the  note  elicited  by  percus- 
sion is  lower  in  pitch  with  the  mouth  shut  than  with  open  mouth. 

Auscultation  reveals  the  presence  of  moist  rales  resulting  from  the  softening 
and  breaking  down  of  the  tuberculous  deposits.  Over  cavities  the  breathing 
is  cavernous  or  amphoric  and  the  voice  possesses  similar  quantities;  pector- 
iloquy upon  whispering  or  speaking  aloud  may  be  present.  The  amphoric 
quality  is  given  to  the  breathing  if  the  cavity  walls  are  firm  and  smooth,  while 
with  softer  walls  a  cavernous  quality  is  transmitted  to  the  voice.  Gurgling 
rales  may  be  caused  by  the  air  passing  through  the  fluid  contents  of  a  cavity. 

The  diagnosis  of  chronic  phthisis  presents  difficulties  during  the  early  stages 
only;  unfortunately  the  presence  of  the  bacillus  in  the  sputum  is  not  likely 
to  occur  until  there  is  ulceration  or  disintegration  of  the  tuberculous  nodules. 
It  is  most  important  that  the  diagnosis  should  be  made  as  early  in  the  disease 
as  possible  for  at  this  time  treatment,  properly  applied,  is  able,  in  most  instances 
to  effect  a  cure.  The  early  physical  signs  upon  which  stress  should  be  laid 
are  the  presence  of  slight  dulness  and  diminished  breathing  and  prolonged 
expiration  at  the  apices,  together  with  whispering  bronchophony,  a  trans- 
mission of  the  heart  sounds  toward  the  apices  and  an  accentuation  of  the 
second  pulmonic  sound.  These  last  three  signs  are  obtainable  two  to  three 
months  before  the  X-ray  will  give  a  shadow.  An  increased  rapidity  of  the 
pulse,  slight  evening  rises  of  temperature,  coupled  with  a  flushed  cheek,  a 
dilated  pupil  and  perhaps  loss  of  flesh,  are  always  suspicious.  Streaks  of 
blood  in  the  expectoration,  though  these  may  come  from  the  naso-pharynx, 
should  always  lead  the  physician  to  make  a  most  careful  physical  examination. 
It  may  be  stated  that  the  patient  in  whom  a  pulmonary  haemorrhage  is  an 
early  symptom  is  fortunate  since  it  induces  him  to  consult  the  medical  man 
and  to  watch  his  condition  most  carefully. 

The  tuberculin  test  may  be  employed  in  dubious   instances;  it  is  without 


TUBERCULOSIS.  169 

danger  and  is  usually  reliable.  Its  technique  is  as  follows:  A  hypodermatic 
injection  of  -^^  of  a  grain  (o.ooi)  of  pure  tuberculin  is  given.  Should  no 
febrile  reaction  ensue  within  10  or  12  hours  the  dose  is  doubled  2  or  3  days 
later  and  is  progressively  increased  until  j2"  o^  ^  grain  (0.005)  is  given.  If  no 
rise  of  temperature  is  evident  after  this  dosage  tuberculosis  is  probably  absent. 
The  agglutination  and  serum  tests  advocated  by  Arloing  and  Courmont 
may  prove  to  be  very  useful.  Early  in  the  disease  the  Rontgen  ray  has  only 
a  limited  use  in  the  diagnosis  since  the  only  noticeable  abnormality  is  a 
diminished  excursion  of  the  diaphragm  upon  the  affected  side.  Areas  of 
consolidation  are  indicated  by  distinct  shadows  and  special  infiltrations  may 
be  evidenced  by  a  blurred  appearance  upon  the  plate. 

Fibroid  Phthisis. 

In  this  disease,  associated  with  the  tuberculous  process,  there  is  a  produc- 
tive inflammation  of  the  lung  resulting  in  an  increased  growth  of  fibroid 
tissue.  The  condition  is  gradual  in  onset  and  it  may  occur  following  chronic 
ulcerative  phthisis  or  it  may  be  engrafted  upon  a  tuberculous  broncho- 
pneumonia or  pleurisy.  The  lung  is  firm,  tough  and  grayish  on  section  as  a 
result  of  the  over-growth  of  fibrous  tissue;  the  bronchi  may  be  dilated  and 
bronchiectatic  cavities  are  often  present;  tuberculous  cavities  are  observed  at 
the  apices;  cheesy  foci  surrounded  by  fibrous  tissue  may  be  present;  in  the 
two  last  lesions  tubercle  bacilli  are  to  be  found.  While  one  lung  is  in  the 
condition  described  the  other  may  be  emphysematous  or  contain  miliary 
tubercles.  The  right  heart,  and  sometimes  the  left  as  well,  is  hypertrophied 
and  there  may  be  amyloid  degeneration  of  the  viscera. 

Symptoms.  Cough  is  present  and  is  frequently  paroxysmal,  but  this, 
with  the  other  symptoms,  emaciation,  fever,  etc.,  is  less  pronounced  than  in 
ulcerative  phthisis.  The  sputum  is  often  profuse,  owing  to  the  presence  of 
bronchiectatic  and  other  cavities,  and  may  be  fcetid.  Bacilli  are  less  easily 
found  than  in  ordinary  chronic  phthisis.  Pulmonary  haemorrhage  may 
occur  and  oedema  of  the  feet  may  result  from  failure  of  the  heart's  action. 
The  course  of  the  disease  is  usually  protracted. 

Physical  Signs.  The  chest  wall  over  the  diseased  lung  is  sunken  and 
the  heart  may  be  displaced  owing  to  retraction  of  the  lung.  The  intercostal 
spaces  are  narrow  and  the  area  of  the  cardiac  apex  beat  may  be  much  en- 
larged. The  characteristic  percussion  note  is  dull  and  high-pitched;  vocal 
fremitus  is  diminished.  Auscultation  may  reveal  the  presence  of  cavities, 
especially  at  the  apices,  elsewhere  there  are  areas  of  bronchial  breathing  and 
increased  vocal  resonance,  unless  the  pleura  is  thickened.  Bronchiectatic 
cavities  may  be  present  in  the  middle  or  lower  lobes.  The  signs  of  emphy- 
sema may  be  noted  in  the  other  lung  and  cardiac  murmurs  are  not  infrequent. 


lyo  THE    INFECTIOUS    DISEASES. 

The  Prognosis  of  Chronic  Pulmonary  Tuberculosis. 

In  the  ulcerative  as  well  as  in  the  fibroid  form  of  the  disease,  although  the 
duration  of  the  latter  type  is  longer,  the  prognosis  is  serious,  but  it  is  certain 
that  many  subjects  of  pulmonary  infection  with  tuberculosis  do  spontaneously 
recover.  This  is  proven  by  the  numberless  autopsies,  in  deaths  from  other 
causes,  in  which  healed  tuberculous  lesions  are  found.  In  these  the  tuber- 
cles have  undergone  fibroid  or  calcareous  degeneration.  In  the  encapsulated 
caseous  masses  while  the  process  may  be  considered  inactive  it  cannot  be 
said  to  have  wholly  ceased  to  exist.  Even  patients,  in  whose  sputum  bacilli 
and  elastic  tissue  have  been  demonstrated,  have  recovered;  consequently  in 
the  light  of  the  above  stated  facts  we  may  safely  say  that  pulmonary  tuber- 
culosis is  a  curable  disease. 

The  patients  in  whom  the  prognosis  is  most  favorable  are  those  with  good 
heredity,  previous  robust  health  and  good  digestion,  slow  invasion,  only  slight 
febrile  movement  and  sHght  pulmonary  involvement.  When  the  initial  inflam- 
mation is  pleuritic,  recovery  may  be  considered  probable,  while  the  oppo- 
site is  true  of  sujects  with  frequent  pulmonary  haemorrhages. 

The  average  duration  of  the  disease  differs,  being,  according  to  the  statis- 
tics of  different  observers,  from  two  and  a  half  to  seven  years.  Proper  treatment 
will,  in  the  great  majority  of  instances,  render  the  patient  more  comfortable 
and  materially  prolong  his  life. 

Prophylaxis.  This  consideration  is  quite  as  important  as  treatment,  for 
in  the  light  of  our  present  knowledge  the  disease  is  distinctly  preventable  in 
most  instances. 

The  public  should  be  educated  by  such  means  as  those  employed  by 
the  Department  of  Health  of  New  York  City,  and  pulmonary  tuberculosis 
should  be  considered  a  reportable  disease  on  account  of  its  infectious 
character.  The  following  is  a  copy  of  a  circular  issued  and  circulated  by 
the  New  York  Health  Department  indicating  the  attempt  that  is  being 
made  to  awaken  the  masses  to  the  importance  of  the  crusade  against 
tuberculosis. 

"  Consumption  is  a  disease  of  the  lungs,  which  is  taken  from  others,  and  is 
not  simply  caused  by  colds,  although  a  cold  may  make  it  easier  to  take  the 
disease.  It  is  caused  by  very  minute  germs,  which  usually  enter  the  body 
with  the  air  breathed.  The  matter  which  consumptives  cough  or  spit  up 
contains  these  germs  in  great  numbers — frequently  millions  are  discharged  in  a 
single  day.  This  matter,  spit  upon  the  floor,  wall  or  elsewhere,  dries  and 
is  apt  to  become  powdered  and  float  in  the  air  as  dust.  The  dust  contains 
the  germs,  and  thus  they  enter  the  body  with  the  air  breathed.  This  dust 
is  especially  likely  to  be  dangerous  within  doors.  The  breath  of  a  consump- 
tive does  not  contain  the  germs  and  will  not  produce  the  disease.     A  well 


TUBERCULOSIS.  171 

person  catches  the  disease  from  a  consumptive  only  by  in  some  way  taking 
in  the  matter  coughed  up  by  the  consumptive. 

"  Consumption  can  often  be  cured  if  its  nature  be  recognized  early  and  if 
proper  means  be  taken  for  its  treatment,  hi  a  majority  of  instances  it  is 
not  a  fatal  disease. 

"It  is  not  dangerous  to  live  with  a  consumptive,  if  the  matter  coughed  up 
by  him  be  promptly  destroyed.  This  matter  should  not  be  spit  upon  the  floor, 
carpet,  stove,  wall  or  sidewalk,  but  always,  if  possible,  in  a  cup  kept  for  that 
purpose.  The  cup  should  contain  water  so  that  the  matter  will  not  dry,  or 
better,  carbolic  acid  in  a  five  percent,  watery  solution  (six  teaspoonfuls  in  a 
pint  of  water).  This  solution  kills  the  germs.  The  cup  should  be  emptied 
into  the  water  closet  at  least  twice  a  day,  and  carefully  washed  with  boiling 
water. 

"  Great  care  should  be  taken  by  consumptives  to  prevent  their  hands, 
faces  and  clothing  from  becoming  soiled  with  the  matter  coughed  up.  If  they 
do  become  thus  soiled,  they  should  be  at  once  washed  with  soap  and  hot  water. 
Men  with  consumption  should  wear  no  beards  at  all,  or  only  closely  cut  mus- 
taches. When  consumptives  are  away  from  home,  the  matter  coughed  up 
should  be  received  in  a  pocket  flask  made  for  this  purpose.  If  cloths  must 
be  used,  they  should  be  immediately  burned  on  returning  home.  If  hand- 
kerchiefs be  used  (worthless  cloths,  which  can  be  at  once  burned,  are  far 
better),  they  should  be  boiled  at  least  half  an  hour  in  water  by  themselves  before 
being  washed.  When  coughing  or  sneezing,  small  particles  of  spittle  con- 
taining germs  are  expelled,  so  that  consumptives  should  always  hold  a  hand- 
kerchief or  cloth  before  the  mouth  during  these  acts;  otherwise,  the  use  of 
cloths  and  handkerchiefs  to  receive  the  matter  coughed  up  should  be  avoided 
as  much  as  possible,  because  it  readily  dries  on  these,  and  becomes  separated 
and  scattered  into  the  air.  Hence,  when  possible,  the  matter  should  he  received 
into  cups  or  flasks.  Paper  cups  are  better  than  ordinary  cups,  as  the  former 
with  their  contents  may  be  burned  after  being  used.  A  pocket  flask  of  glass, 
metal,  or  pasteboard  is  also  a  most  convenient  receptacle  to  spit  in  when  away 
from  home.  Cheap  and  convenient  forms  of  flasks  and  cups  may  be  purchased 
at  many  drug  stores.  Patients  too  weak  to  use  a  cup  should  use  moist  rags, 
which  should  at  once  be  burned.  If  cloths  are  used  they  should  not  be  carried 
loose  in  the  pocket,  but  in  a  waterproof  receptacle  (tobacco  pouch),  which 
should  be  frequently  boiled.  A  consumptive  should  never  swallow  his  expec- 
toration. 

"  A  consumptive  should  have  his  own  bed,  and,  if  possible,  his  own  room. 
The  room  should  always  have  an  abundance  of  fresh  air — the  window  should 
be  open  day  and  night.  The  patient's  soiled  wash-clothes  and  bed  linen 
should  be  handled  as  little  as  possible  when  dry,  but  should  be  placed  in  water 
until  ready  for  washing. 


172  THE    INFECTIOUS    DISEASES. 

"If  the  matter  coughed  up  be  rendered  harmless,  a  consumptive  may  fre- 
quently not  only  do  his  usual  work  without  giving  the  disease  to  others,  but  may 
also  thus  improve  his  own  condition  and  increase  his  chances  of  getting  well. 

"  Whenever  a  person  is  thought  to  be  suffering  from  consumption,  the 
Department  of  Health  should  be  notified  and  a  medical  inspector  will  call 
and  examine  the  person  to  see  if  he  has  consumption,  providing  he  has  no 
physician,  and  then,  if  necessary,  will  give  proper  directions  as  to  treatment. 

"  Rooms  which  have  been  occupied  by  consumptives  should  be  thoroughly 
cleaned,  scrubbed,  whitewashed,  painted  or  papered  before  they  are  again 
occupied.  Carpets,  rugs,  bedding,  etc.,  from  rooms  which  have  been  occu- 
pied by  consumptives,  should  be  disinfected.  Such  articles,  if  the  Depart- 
ment of  Health  be  notified,  will  be  sent  for,  disinfected  and  returned  to  the 
owner  free  of  charge,  or,  if  he  so  desire,  they  will  be  destroyed. 

"  When  consumptives  move  they  should  notify  the  Department  0}  Health. 

"  Consumptives  are  warned  against  the  many  widely  advertised  cures,  specific 
and  special  methods  of  treatment  of  consumption.  No  cure  can  he  expected 
from  any  kind  of  medicine  or  method,  except  the  regularly  accepted  treatment, 
which  depends  upon  pure  air,  an  out-of-door  life  and  nourishing  food.'' 

Legislation  with  reference  to  the  sanitary  condition  of  tenement  houses, 
to  the  inspection  of  the  sources  of  our  meat  and  milk  supply  and  against 
promiscuous  expectoration  is  a  necessary  step  in  prevention,  as  well  as 
thorough  disinfection  of  rooms  and  their  contents,  after  occupation  by  tuber- 
culous individuals,  and  the  establishment  of  municipal,  state  or  even  federal 
sanatoriums  and  tuberculosis  dispensaries.  At  least  one  of  the  hospitals  of 
New  York  City  has  a  corps  of  visiting  nurses  who  go  to  the  houses  of  patients 
who  are  under  treatment  at  the  institution's  out-patient  department  and 
instruct  the  family  in  the  necessity  of  cleanliness,  in  the  care  of  sputum,  etc. 

The  sputum,  being  the  chief  means  by  which  the  disease  is  disseminated, 
should  be  thoroughly  and  at  once  destroyed.  It  should  be  received  into 
earthen  or  enamel- ware  cups  in  which  a  i  to  1,000  solution  of  mercury 
bichloride  or  a  4  percent,  solution  of  phenol  is  constantly  kept;  where  it  is 
impossible  to  procure  these  germicides  water  should  be  substituted  since  the 
bacilli  unless  dried  are  not  carried  by  the  air,  or  the  patient  may  expectorate 
into  bits  of  old  muslin  or  even  a  Japanese  napkin  which  is  to  be  immediately 
burned.  The  burnable  pasteboard  sputum  cup  is  a  useful  and  safe  appli- 
ance. All  permanent  receptacles  for  sputum  should  be  scalded  out  with 
boiling  water  at  least  once  a  day. 

The  proper  care  of  delicate  children,  whether  born  of  tuberculous  parents 
or  not,  is  most  important.  The  tuberculous  mother  should  not  nurse  her 
child  and  the  general  surroundings  of  the  predisposed  infant  should  be  of 
the  most  healthful  character.  Catarrhal  diseases  are  much  to  be  feared, 
consequently  the  child  should  not  be  allowed  out  of  doors  upon  cloudy,  damp 


TUBERCULOSIS.  1 73 

days  during  the  cold  months  and  the  condition  of  the  upper  air  passages 
should  be  kept  as  healthful  as  possible.  The  importance  of  the  removal 
of  adenoids  and  hypertrophied  tonsils  cannot  be  over-estimated.  Proper 
clothing — woolen  next  the  skin — should  be  worn.  After  the  child's  bath, 
sponging  with  cold  water — 60°  to  70°  F.  (15.5°  to  21°  C.) — is  an  excellent 
method  of  hardening.  The  diet  should  be  plentiful,  plain  and  nourishing 
and  a  liking  for  milk,  if  not  already  present,  should  be  cultivated.  All  ill- 
nesses, no  matter  how  insignificant  should  be  carefully  treated  and  the  admin- 
istration of  such  tonics  as  iron,  especially  syrupus  ferri  iodidi,  arsenic  ancf 
codliver  oil,  may  be  attended  with  benefit.  As  the  child  grows  older  he  should 
be  encouraged  to  lead  an  out-door  life,  exposure  to  cold  and  wet,  however, 
being  avoided,  and  in  the  pursuance  of  gymnastic  and  respiratory  exercises. 
When  it  becomes  necessary  to  choose  his  life-occupation  one  which  will  tend 
to  keep  the  subject  in  the  open  air  as  much  as  possible  is  to  be  preferred. 

Protection  by  Immunization.  Von  Behring  claims  to  have  discovered  a 
method  of  immunization  of  man  which  is  sure,  rapid  and  without  danger. 
He  believes  that  the  immunizing  substance  is  contained  in  the  bodies  of  the 
tubercle  bacilli  and  acts  by  combining  with  certain  living  cellular  elements. 
His  theories  have  been  proven  by  animal  experimentation  and  he  believes 
that  it  is  possible  by  the  same  methods  to  protect  the  human  subject  against 
tuberculous  infection.  The  discovery  is  not  to  be  given  to  the  world  until 
further  experimentation  and  clinical  study  have  been  carried  out.  A  state- 
ment like  the  above  coming  from  Professor  von  Behring  carries  much  weight. 

Treatment.  Pulmonary  phthisis  is  an  infection  and  should  be  treated 
as  such.  The  patient's  life  should  be  regulated  and  his  condition  watched 
as  carefully  as  in  enteric  fever  or  diphtheria.  Each  patient  is  a  law  into 
himself,  consequently  no  one  method  is  applicable  in  all  instances  and  seldom 
does  any  single  method  succeed  in  a  given  subject,  the  best  results  being  ob- 
tained by  a  combination  of  appropriate  modes  of  treatment.  Climatic  treat- 
ment, dietetic  treatment,  drug  treatment,  each  has  a  distinct  place  but  we 
should  not  be  satisfied  to  employ  them  singly;  we  should  use  all  means  at  our 
disposal,  keep  up  the  patient's  nutrition,  constantly  watch  him  in  every  phase 
of  his  disease  and  work  continuously  to  benefit  him.  The  special  consider- 
ations are  to  improve  the  nutrition  by  proper  hygienic  mode  of  life  and  feed- 
ing; to  arrest  the  tuberculous  process;  and  to  relieve  the  unpleasant  symp- 
toms as  they  arise. 

a.  Climatic  Treatment.  When  it  is  possible  to  remove  the  patient,  a  suit- 
able climate  should  be  sought  as  soon  as  the  diagnosis  is  suspected.  The 
ideal  climate  is  dry,  of  equable  temperature  and  one  which  affords  the  largest 
number  of  sunny  days;  such  a  one  is,  however,  impossible  to  find  since  no 
dry  climate  possesses  an  equable  temperature,  consequently  we  should  select 
a  region  the  meteorological  characteristics  of  which  approach  as  nearly  as 


174  THE    INFECTIOUS    DISEASES. 

possible  to  this  ideal.  In  many  instances  it  will  be  impossible  to  choose  a 
climate  for  a  given  patient  and  the  only  possible  method  of  selection  is  to  experi- 
ment until  one  is  found  in  which  the  subject  does  well.  In  general  it  may  be 
stated  that  an  altitude  of  from  2,000  to  2,500  feet  is  more  favorable  than  a 
low  lying  region.  Another  important  consideration  is  that  the  patient  must 
not  be  sent  to  a  place  where  good  accommodations  and  food  cannot  be 
obtained. 

Evans  gives  the  following  useful  classification  of  climates. 

1.  Cool  moderately  moist  climate,  general  elevation  2,000  feet — the  western 
slope  of  the  Appalachian  range,  the  Adirondacks,  Catskills,  AUeghanies,  and 
Cumberland  mountains. 

2.  Moderately  warm  and  moist  climate,  elevation  2,250  feet — Asheville, 
N.  C;  Aiken,  S.  C;  Marietta  and  Thomasville,  Ga. 

3.  Warm  and  moist  climate — the  coast  regions  of  Florida  and  Southern 
California. 

4.  Warm  and  moderately  dry  climate,  elevation  about  2,000  feet — South- 
western Texas  and  Southern  California  inland. 

5.  Cool  and  moderately  dry  climate,  elevation  about  1,000  feet — Min- 
nesota, Nebraska  and  Dakota. 

6.  Cool  and  dry  climate,  elevation  4,000  to  7,000  feet — Montana,  Wyoming, 
Colorado,  Northern  New  Mexico  and  Western  Kansas;  Davos  and  St.  Moritz, 
Europe. 

7.  Warm  and  dry  climate,  elevation  3,000  to  5,000  feet — Southern  New 
Mexico  and  Southern  Arizona. 

The  Adirondacks  are  a  very  favorite  resort  for  the  tuberculous  of  the  vicinity 
of  New  York  City  and,  even  though  the  elevation  is  considerable,  the  per- 
manence of  an  established  cure  is  not  jeopardized  by  a  return  to  sea-level. 
The  patients  who  do  best  at  an  altitude  are  those  in  whom  the  disease  has  not 
of  advanced  infections,  especially  if  emphysema  or  cardiac  weakness  is  present, 
gone  on  to  cavity  formation  and  whose  nutrition  is  good;  the  opposite  is  true 
Such  conditions  usually  contra-indicate  removal  to  a  high  altitude  and  the 
patient  is  more  likely  to  be  benefited  by  a  moist  and  warrti  climate  than  by 
one  which  is  cold  and  dry.  In  conclusion  it  may  be  stated  that  life  in  the 
open  air  is  essential  in  whatever  climate  the  patient  may  be. 

Hygienic  treatment  consists  in  first  securing  ventilation  and  sunlight. 
The  dwelling  should  be  situated  upon  high  rather  than  low  ground  and  should 
be  as  accessible  to  the  sun  as  possible.  The  importance  of  the  latter  considera- 
tion is  shown  by  the  fact  that  instance  after  instance  of  tuberculosis  continued  to 
occur  in  certain  houses  in  Massachusetts  until  the  removal  of  the  many 
trees  about  them.  After  this  was  done  the  disease  disappeared  as  if  by 
magic.  Proper  drainage  is  important  and  the  patient's  apartment  should 
be  one  to  which  the  sunlight  has  access  for  as  much  of  the  day  as  possible. 


TUBERCULOSIS.  175 

Ventilation  by  a  fireplace  is  to  be  advised  and  the  patient  should  sleep  with 
the  windows  open  even  in  the  coldest  weather,  but  protection  from  draughts 
must  be  secured.  The  air  within  the  sleeping-room  should  be  identical 
with  that  out  of  doors. 

During  the  day  the  patient  should  spend  as  much  of  the  time  in  the  open 
air  as  possible  and  should  take  such  exercise  in  moderation  as  the  condition 
of  his  circulatory  apparatus  will  allow.  Sitting  in  the  sunlight  should  be 
encouraged  but  it  is  better  to  keep  in  motion  if  the  physical  condition  permits. 

The  employment  of  hydrotherapeutic  treatment  as  a  curative  measure 
may  be  neglected;  it  is,  however,  important  in  prophylaxis.  Daily  baths 
should  be  taken  in  order  to  keep  the  skin  and  circulation  active.  Cool 
water  may  be  used  but  not  unless  the  rub  down  after  the  bath  is  succeeded 
by  a  good  reaction.     The  risk  of  chilling  the  body  should  not  be  taken. 

Breathing  exercises  are  important  and  by  their  means  the  lung  capacity 
and  chest  expansion  are  capable  of  a  considerable  increase.  They  consist 
in  taking  several  successive  deep  breaths,  the  patient  standing  upright  in  the 
open  air  meanwhile.  Each  breath  is  held  for  a  few  seconds  and  then  slowly 
exhaled.  In  proper  instances,  the  condition  of  the  heart  permitting,  calis- 
thenics in  moderation  are  excellent.  The  exercises  which  comprise  the  "  set- 
ting up  drill"  of  the  United  States  Army  may  be  employed. 

The  patient's  clothing  is  an  important  consideration,  wool,  of  weight  varied 
according  to  the  temperature,  should  be  worn  next  the  skin  at  all  seasons 
of  the  year,  both  day  and  night.  As  a  sleeping  dress  nothing  is  better  than 
pajamas  of  flannel  or  a  night-gown  reaching  to  the  feet. 

The  open-air  treatment  has  been  much  exploited  of  late  and  is  undoubtedly 
a  method  of  great  value.  It  may  be  employed  at  home  in  the  city  or  country 
or  in  institutions.  It  may  be  difficult  to  carry  out  in  the  city  but  if  the  phys- 
ician insists  upon  its  importance  it  will  be  possible  to  overcome  many  obsta- 
cles. The  roof  or  back  yard  may  be  used  upon  pleasant  days,  and  an  ordi- 
nary steamer  chair  provided  with  cushions  and  blankets  makes  an  excellent 
couch  if  it  is  necessary  that  the  patient  recline.  Days  upon  which  it  is  not 
advisable  to  send  the  patient  actually  out  of  doors  he  should  recline,  warmly 
wrapped,  if  necessary,  before  the  open  window  of  his  apartment  which  should 
be  the  most  sunny  and  airy  room  in  the  house.  At  night  the  windows 
should  be  open  so  that,  unless  the  weather  absolutely  forbids,  the  patient 
spends  practically  all  his  time  in  the  open  air.  Such  symptoms  as  fever, 
sweats  and  haemoptysis  should  not  be  allowed  to  interfere  with  the  treatment. 

The  sanatorium  treatment  has  recently  been  developed  to  a  considerable 
degree.  The  great  advantage  of  institutional  treatment  is  that  the  patient's 
mode  of  life  is  in  every  way  regulated  upon  the  lines  most  beneficial  to  him. 
Exercise,  sleep,  diet,  amusement,  etc.,  are  arranged  in  accordance  with  the 
most  hygienic  methods.     Emphasis  must  be  laid  upon  the  importance  of 


lyS  THE    INFECTIOUS    DISEASES. 

the  establishment  of  pubhc  sanatoriums  near  large  cities  so  as  to  be  avail- 
able for  early  infections  and  patients  of  moderate  mean. 

Tent  life  for  the  tuberculous.  This  mode  of  treatment  is  only  another  phase 
of  the  out-door  fresh  air  method.  Tents  or  tent  cottages  may  be  con- 
structed according  to  any  desirable  plan  and  life  in  these  is  practically  an 
existence  in  the  open  air. 

Dietetic  treatment  is  perhaps  the  most  important  consideration  in  the 
management  of  pulmonary  tuberculosis  but  presents  certain  difficulties. 
The  importance  of  proper  feeding  cannot  be  too  strongly  emphasized;  the 
well-nourished  organism  is  able  to  throw  off  tuberculous  infection  and  it  is 
certainly  probable  that  the  poorly  nourished  organism  which  is  the  subject 
of  a  tuberculous  infection  can  better  combat  this  prejudicial  condition  if  its 
nutrition  is  improved  in  every  possible  way.  Many  patients  will  state  that 
they  cannot  eat,  yet  if  they  are  encouraged  to  try,  they  will,  before  the  meal 
is  finished,  give  evidence  of  a  very  respectable  appetite. 

Any  system  of  feeding  which  departs  markedly  from  the  proper  propor- 
tion of  proteids,  fats  and  carbohydrates  is  not  a  wise  one,  as  is  shown  by  the 
failure  of  the  raw-beef  and  hot- water  treatment;  this  fails  in  a  large  pro- 
portion of  patients  because  the  amount  of  albuminous  material  is  so  great  that 
it  over-taxes  elimination.  The  Debove  method  of  treatment  by  over-feeding 
(see  p.  629)  may  be  followed  by  considerable  gains  of  flesh  but  unfortunately, 
while  the  increase  in  weight  is  going  on,  the  tuberculous  process  remains 
stationary,  and  the  method  has  the  additional  disadvantage  that  very  careful 
watching  of  the  patient  is  required  to  prevent  the  disagreeable  consequences 
of  over-feeding.  This  mode  of  feeding  is  best  reserved  for  patients  with 
tuberculous  laryngitis  where  it  has  one  distinct  advantage  that  is  of  great 
value  in  certain  instances.  It  is  a  curious  fact  that  these  patients,  who  are 
often  prone  to  vomit,  a  very  distressing  symptom  in  tuberculosis  of  the  larynx, 
seldom  do  so  when  food  is  introduced  by  the  stomach  tube. 

The  proper  diet  for  patients  suffering  from  pulmonary  tuberculosis  should 
consist  of  meats,  starches  and  fats,  with  an  excess  of  the  last,  and  a  certain 
amount  of  phosphates.  Light  and  nutritious  food  should  be  given,  it  should 
be  easily  digestible  and  the  meals  should  be  frequent.  They  should  be  sepa- 
rated into  those  containing  the  bulk  of  the  starchy  food  and  those  consisting 
chiefly  of  proteids.  Three  to  three  and  a  half  hours  should  be  allowed  for 
the  digestion  of  the  heavier  meals  so  that  the  stomach  shall  be  fairly  emptied 
before  it  receives  the  next  consignment  of  food. 

The  first  meal  should  be  at  about  7  A.  M.  when  the  patient  takes  a  glass 
of  warm  (not  hot)  milk  containing  a  tablespoonful  of  strong  coffee  made 
according  to  the  French  method,  or,  if  the  previous  night  has  been  an  exhaust- 
ing one,  a  dessertspoonful  of  rum  or  other  spirit  which  has  previously  been 
mixed  with  enough  water  to  reduce  its  alcohol  content  to  not  more  than  5 


TUBERCULOSIS.  177 

percent.,  otherwise  the  spirit  will  coagulate  the  albumin  of  the  milk  and  render 
it  less  digestible.  Breakfast  is  taken  at  9  A.  M.  The  patient  is  allowed  eggs 
cooked  in  any  way  except  by  frying,  although  if  frying  is  an  essential  it  may 
be  done  in  the  Italian  method,  i.e.,  in  olive  oil.  Prepared  thus  eggs  are  much 
less  indigestible  than  when  fried  in  lard.  Bread  is  also  permitted  and  mar- 
malade if  the  patient  likes.  Finnan  haddie  pleases  certain  patients,  when  it  is 
cured  by  smoking  and  without  salt,  and  it  seems  to  agree  with  them  although 
it  is  a  theoretically  incorrect  article  of  diet.  Toasted  bread  or  good  rolls 
(not  hot)  are  allowable  and  bread  and  butter,  milk  and  coffee  may  be  used 
for  variety. 

About  eleven  o'clock  the  patient  has  the  second  breakfast,  which  usually 
consists  of  a  little  cocoa  from  which  the  fat  has  been  taken  out.  Cocoa  butter 
is  one  of  the  most  indigestible  fats,  therefore  it  should  be  removed,  or 
or  else  predigested.  The  patient  may  also  have  coffee,  a  little  bread,  a  little 
soup  or  a  little  beef  extract.  An  eggnog  is  permissible,  and  kumyss  or  mat- 
zoon  is  often  acceptable. 

The  dinner  should  be  served  about  one  o'clock  in  the  afternoon,  and  should 
be  the  meal  of  the  day.  The  patients  may  have  any  kind  of  meat  they  relish, 
except  salted  meat,  but  it  must  not  be  fried.  Potatoes,  fresh  vegetables, 
fruits,  and  puddings  may  also  be  allowed.  Coffee,  tea,  or  possibly  a  bottle 
of  light  beer,  may  be  added. 

About  four  o'clock  in  the  afternoon  they  should  have  a  little  meat  extract 
with  toasted  bread,  and  about  five  o'clock,  a  little  more  should  be  given. 
About  seven  o'clock  in  the  evening  comes  supper,  consisting  chiefly  of  farina- 
ceous food.  Many  of  these  patients  like  what  is  known  as  hasty-pudding 
which  is  made  by  putting  corn  meal  into  a  kettle  with  water,  and  stirring  it 
while  it  is  boiling,  seasoning  to  taste.  Various  jellies,  beef  extracts,  and 
gruels  are  useful  at  this  time.  If  the  patient  is  awake  at  eleven  a  cup  of  milk 
or  hot  soup  may  act  as  a  hypnotic. 

Patients  who  exhibit  a  hectic  temperature  are  better  without  alcohol  after 
the  I  P.  M.  dinner  because  the  alcohol  seems  to  increase  the  fever.  In  general 
alcohol  should  be  taken  only  in  moderate  amount  and  well  diluted.  After 
noon  only  beer  is  to  be  permitted,  with  perhaps,  stout  upon  retiring. 

The  starchy  foods,  since  upon  these  we  must  depend  to  improve  nutrition, 
should  be  given  with  as  little  liquid  as  possible  and  their  digestibility  should 
be  increased  by  the  addition  of  a  malt  extract,  which  in  itself  is  nutritious 
and  contains  diastase.  All  liquid  malt  extracts  are  utterly  useless  for  the 
transformation  of  starch  into  dextrin  and  maltose,  because  they  contain  alcohol 
which  inhibits  the  effect  on  the  starch,  and  because  they  contain  acids,  gener- 
ated in  the  process  of  fermentation,  which  also  inhibit  the  action  of  the  diastase. 
The  semi-solid  extracts  of  malt  convert  starch  into  sugar.  This  conversion 
commences  to  take  place  in  the  mouth.  For  the  first  thirty  or  forty  minutes 
12 


lyS  THE    INFECTIOUS    DISEASES. 

after  food  has  been  taken  into  the  stomach,  this  process  goes  on.  It  later 
stops,  but  recommences  in  the  duodenum  and  continues  until  all  the  starches 
are  converted  into  dextrin,  and  finally  into  maltose.  That  this  conversion 
continues  in  the  stomach  has  been  proven  conclusively  by  Kellogg.  The 
great  disadvantage  of  most  of  the  active  preparations  of  malt  is  their  viscosity, 
which  renders  them,  after  a  little  time,  objects  of  disgust.  It  is  now  possible 
to  obtain  a  preparation  of  malt,  which  contains  from  four  to  five  percent, 
diastasic  converting  power.  With  such  a  preparation  as  maltzyme  we  can 
be  assured  that  the  starches  will  be  digested.  The  starches  are  for  nourish- 
ment, for  the  generation  of  heat,  and  for  the  formation  of  fat.  This  is  just 
what  one  wants  for  a  tuberculous  patient.  Further  than  this  recent  investi- 
gations tend  to  show  that  the  sugars  are  important  in  the  generation  of  force. 
That  is  to  say:  Under  a  constant  diet  more  than  a  proportionately  larger 
amount  of  energy  is  developed  if  sugar  be  added  to  the  dietary. 

Life  in  the  open  air  is  a  great  stimulant  to  the  appetite  and  an  occasional 
gastric  lavage  may  remove  the  mucus  from  a  sluggish  stomach  and  increase 
the  desire  for  food ;  a  dose  of  one  of  the  vegetable  bitters  taken  before  meals 
now  and  then  is  an  excellent  measure.  Of  these  perhaps  the  best  is  condur- 
ango,  dose  of  the  fluidextract  20  to  30  drops  (1.33  to  2.0).  Nux  vomica  and 
gentian   are   also   to  be  recommended. 

Medicinal  Treatment.  Creosote  has  been  employed  in  pulmonary  tuber- 
culosis since  1842  and  is  perhaps  the  only  remedy  which  has  never  been  aban- 
doned. Its  chief  disadvantage  is  that  it  is  often  irritant  to  the  stomach  and 
the  kidneys  but  this  can  be  avoided  in  great  measure  by  the  use  of  creosote 
carbonate  or  of  pure  beechwood  creosote.  The  former  is  preferable  since 
it  may  be,  on  account  of  its  less  irritant  qualities,  administered  in  much  larger 
dosage.  It  contains  92  percent,  of  creosote  and  may  be  given  in  dose  of  from 
15  to  60  minims  (i.o  to  4.0)  in  a  wineglass  (60.0)  of  sherry  after  meals  or  in 
milk  or  bouillon.  It  may  also  be  given  in  codliver  oil,  i  part  to  10.  Creosote 
carbonate  is  slowly  absorbed  and  is  probably  eliminated  chiefly  by  the  bron- 
chial mucous  membrane.  It  is  the  drug  upon  which  we  place  our  chief  reli- 
ance in  treating  pulmonary  tuberculosis. 

Creosote  itself  may  be  used  in  various  ways  but  it  is  very  important  that 
it  should  be  pure;  it  is  frequently  contaminated  with  phenol  the  presence  of 
which  may  be  proven  by  moistening  a  match  with  the  suspected  fluid;  if 
impure  the  wood  is  stained  bluish  Creosote  may  be  administered  in  the  form 
of  an  emulsion  with  codliver  oil  and  acacia,  with  codliver  oil  and  the  hj'po- 
phosphites,  with  syrup  of  wild  cherry  and  acacia,  2  minims  (0.3)  of  creosote 
to  I  drachm  (4.0)  of  the  emulsion  in  each  case — or  in  a  mixture  of  glycerin 
and  whiskey.  The  dose  of  creosote  should  be  ^  to  2  minims  (0.03  to  0.13)  given 
thrice  daily  and  gradually  increased  to  20  to  25  minims  (i  33  to  1.66) 
in  the  24  hours.     Given   in  pills  coated  with  keratin,  which  will  dissolve 


TUBERCULOSIS,  1 79 

only  in  the  intestine,  a  daily  dosage  of  from  45  to  50  minims  (3.0  to  3.3)  can 
be  reached  without  inconvenience.  The  following  prescriptions  may  be 
found  useful:  I^  creosote  oi  (4-o),  tincturae  nucis  vomicae  oss  (15.0),  tincturae 
gentianae  compositae  q.  s.  ad  giv  (120.0).  Misce  et  signa,  one  teaspoonful 
3  times  a  day  after  meals;  I^  creosoti  5i  (4-o),  balsami  tolutani  gr.  cv  (7.0), 
terpini  hydratis  gr.  15  (i.o),  acidi  benzoici,  q.  s.  Misce  et  divide  in  pilulas 
numero  Ixxx.  Signa.  Take  10  pills  per  day.  The  hypodermatic  administra- 
tion of  creosote  in  sterile  oil  requires  a  special  apparatus  and  is  very  tedious 
and  painful.  Creosote  by  inhalation  is  especially  indicated  when  the  sputum 
is  foetid.  The  sponge  of  a  perforated  zinc  inhaler  is  wet  with  a  mixture  of 
equal  parts  of  beechwood  creosote,  spirit  of  chloroform  and  alcohol  and  the 
apparatus  is  used  for  15  minutes  in  every  hour. 

If  the  dosage  of  creosote,  when  given  by  mouth,  is  increased  too  rapidly, 
nausea,  epigastric  distress  and  even  vomiting  may  result  and  the  urine  may 
become  darkened  and  contain  blood  and  granular  casts,  but  if  the  increase 
of  dose  is  slow  the  patient  may  acquire  a  tolerance  for  the  drug;  50  minims 
(3-33)  should  be  considered  a  maximum  daily  dosage.  When  it  is  impossible 
to  give  creosote  by  mouth  it  may  be  given  in  enema  as  follows.  This  method 
is  preferable  to  its  hypodermatic  administration  and  is  specially  indicated 
in  tuberculous  diarrhoea  or  enteritis.  The  enema  is  made  up  of  ^  to  i  drachm 
(2.0  to  4.0)  of  creosote  dissolved  in  6  drachms  (25.0)  of  oil  of  sweet  almonds. 
This  is  emulsified  by  the  addition  of  the  yolk  of  an  egg  and  the  whole  is  mixed 
with  6  ounces  (200.0)  of  water.  A  more  easily  made  enema  consists  of  from 
15  to  45  minims  (i.o  to  3.0)  of  creosote  mixed  with  4  to  8  ounces  (125.0 
to  250.0)  of  water.  This  mixture  should  be  thoroughly  agitated  before  ad- 
ministration and  may  be  given  2  or  3  times  daily. 

An  excellent  substitute  for  creosote  is  gomenol,  an  oily  Hquid  analogous 
to  oil  of  cajuput  and  distilled  from  the  leaves  of  Melaleuca  viridiflora;  its 
dosage  is  from  30  to  60  minims  (2.0  to  4.0)  in  capsules  daily.  Another  sub- 
stitute is  guaiacol — 8  minims  (0.5) — 3  times  a  day  or  better,  guaiacol  carbo- 
nate, the  dose  of  which  is  twice  as  large. 

Codliver  oil  is  a  valuable  aid  in  the  treatment  of  tuberculosis.  Pure  oil 
is  unpleasant  to  the  taste  but  fortunately  children  frequently  take  it  with 
avidity.  The  objections  of  older  persons  may  be  avoided  by  giving  it  in 
soft  capsules  or  in  the  ofl&cial  emulsion.  Some  patients  aire  able  to  take  the 
oil  by  previously  rinsing  the  mouth  with  whiskey  or  brandy  or  by  putting  a 
little  salt  in  the  mouth  after  swallowing  the  dose.  To  render  the  oil  less 
unpalatable  10  minims  (0.66)  of  pure  aether  or  a  drop  or  two  of  peppermint 
or  clove  oil  may  be  added  to  each  dose.  One  part  of  essential  oil  of  eucal- 
yptus is  said  to  entirely  do  away  with  odor  and  taste  and  a  nutritious  com- 
bination may  be  made  by  rubbing  together  equal  parts  of  codliver  oil  and 
malt  extract.     Another  method  of  disguise  is  to  add  to  400  parts  of  the  oil 


l8o  THE    INFECTIOUS    DISEASES. 

lo  parts  of  animal  charcoal  and  20  of  ground  roasted  coffee;  the  mixture  is 
digested  on  a  water  bath  at  122°  to  140°  F.  (50°  to  60°  C.)  and  after  standing 
for  three  days  is  filtered  and  stored  in  well-stoppered  bottles.  Iron  may  be 
combined  with  the  oil  as  follows:  I^  olei  morrhuae  5iv  (i5-o),  ferri  et  ammonii 
citratis  gr.  v  (0.33),  potassii  carbonatis  gr.  iii  (0.20),  saccharini  gr.  \  (0.015), 
olei  cari  ttl  J  (0.015),  aquae  destillatae  q.s.  ad  §i  (30.0). 

Codliver  oil  is  considered  as  contraindicated  in  diarrhoea,  haemoptysis, 
dyspepsia,  vomiting  and  fever. 

The  h}'pophosphites  are  useful  especially  in  the  primary  stages  when  our 
prime  object  is  to  improve  the  patient's  nutrition.  It  is  important  that  they 
should  be  chemically  pure  and  neutral  in  reaction,  for  the  presence  of  free 
alkali  or  alkaline  carbonates  quickly  causes  an  atonic  dyspepsia.  The  offi- 
cial syrups  of  mixed  hypophosphites  are  faulty  in  that  each  salt  has  a  pecu- 
liar property;  the  final  effect  of  hypophosphite  medication  is  due  to  the 
beneficial  effect  upon  nutrition  of  the  particular  salt  prescribed.  In  the 
early  stages  of  phthisis  (infiltration)  the  sodium  salt  only  should  be 
administered;  where  cavities  are  present  the  calcium  salt  only  is  indicated, 
provided  that  it  does  not  too  suddenly  check  expectoration,  when  the  sodium 
salt  should  be  resumed.  The  potassium  salt  is  a  valuable  expectorant  in 
chronic  bronchitis  but  its  usefulness  in  phthisis  is  limited.  The  hypophos- 
phites, intelligently  administered,  will  improve  nutrition  and  relieve  certain 
of  the  symptoms  of  pulmonary  tuberculosis,  but  when  given  in  too  large  doses, 
or  simultaneously  with  iron,  arsenic,  strychnine  or  other  stimulants  or  cod- 
liver  oil,  they  are  likely  not  only  to  fail  but  to  cause  digestive  disturbances. 
Quinine  hypophosphite  is  useful  in  the  last  stages  of  the  disease  only,  and  then 
probably  merely  as  a  placebo. 

The  tonics,  especially  iron  and  arsenic,  are  often  useful  to  combat  the 
secondary  anaemia  of  chronic  phthisis.  The  latter  should  not  be  given  to 
alcoholics  or  to  patients  who  suffer  from  gastro-intestinal  disturbances  or 
hasmoptyses.  It  is  often  wise  to  give  the  arsenic  for  3  days  in  the  week 
or  15  or  20  days  in  the  month.  It  may  be  given  in  the  form  of  sodium 
arsenate  gr.  yV  to  I  (0.005  to  0.016),  or  as  Fowler's  solution,  2  to  8  minims 
(0.13  to  0.5)  3  times  a  day.  The  latter  may,  if  necessary,  be  administered 
per  rectum  mixed  with  water  in  dosage  twice  the  size  of  that  given  by  mouth. 
Sodium  cacodylate  which  contains  50  percent,  of  arsenic  may  be  given  in 
pill  form — each  pill  to  contain  ^  of  a  grain  (con) — from  3  to  6  pills  a  day  and 
in  the  anaemia  of  those  predisposed  to  tuberculosis  this  drug  combined  with 
iron  and  ammonium  citrate  is  to  be  recommended. 

The  Treatment  of  Special  Symptoms.  Fever  necessitates  rest,  which  of 
course  may  be  taken  in  the  open  air.  Quinine  and  the  salicylates  are  of  little 
use;  the  former,  if  given  in  dose  large  enough  to  control  the  temperature  is 
very  prone  to  disturb  the  digestion.     Small  doses  of  salipyrine,  acetpheneti- 


TUBERCULOSIS.  l8l 

dine  or  antipyrine  are  often  effectual.  Temperatures  above  103°  F.  (39.5°  C.) 
may  be  relieved  by  sponging  with  cool  water. 

The  cough,  if  slight,  may  be  relieved  by  simple  mixtures  containing  dilute 
hydrocyanic  acid  2  to  3  minims  (0.12  to  0.18)  to  the  dose;  as  vehicles  the 
syrups  of  tolu  or  wild  cherry  may  be  employed.  Syrups,  however,  when 
continued,  are  very  apt  to  disturb  the  gastric  functions.  More  distressing 
cough  necessitates  the  administration  of  heroine  4V  to -2V  of  a  grain  (0.0016 
to  0.0033)  or  codeine  J  to  ^  a  grain  (0.0165  to  0.0033)  every  4  hoiirs.  In  the 
advanced  stages  frequently  only  morphine  wiU  relieve  this  symptom.  Suffi- 
cient quantity  may  be  given  to  control  the  cough  during  sleep  but  not  so  much 
as  to  inhibit  the  expectoration  of  the  accumulations  of  the  night  when  the 
patient  awakes.  This  may  be  facilitated  by  administering  a  glass  of  hot  milk 
or  a  milk  punch.  If  the  bronchial  secretions  are  tough  and  not  easily  raised 
they  may  be  softened  and  their  expectoration  made  less  difl&cult  by  the  admin- 
istration of  soluble  capsules  containing  terpene  hydrate  gr.  v  (0.33)  and 
heroine  gr.  2'V  (0.0033).  Terebene  is  also  useful  in  this  connection  although 
it  may  disturb  the  stomach.  It  may  be  given  in  doses  of  5  to  10  minims 
(0.33  to  0.66)  3  times  a  day  well  diluted.  If  the  cough,  after  examination, 
appears  to  be  due  to  involvement  of  the  larynx  the  measures  described  on 
p.  628  are  applicable. 

Haemoptysis  is  an  important  symptom.  The  patient  should  be  kept  abso- 
lutely at  rest,  in  the  recumbent  position,  but  with  the  shoulders  slightly  raised. 
Cold  applications  should  be  made  to  the  chest  in  the  form  of  the  ice  coil,  the 
ice  bag  or  cold  compresses  wrung  out  in  ice  water,  and  the  patient  may  be 
given  bits  of  ice  to  suck.  The  early  administration  of  a  hypodermatic 
injection  of  morphine  sulphate  J  to  ^  of  a  grain  (0.016  to  0.022)  is  usually 
advisable.  All  measmres  which  increase  the  blood  pressure  should  be  avoided 
and  if  the  arterial  tension  is  high  aconite  may  be  given  in  doses  of  3  to  5, min- 
ims (0.2  to  0.33)  of  the  tincture  every  homr  until  the  desired  effect  is  produced. 
A  very  important  measure  is  the  administration  of  one  of  the  salts  of  calcium 
in  order  to  increase  the  coagulabiUty  of  the  blood.  The  most  effectual  of 
these  is  the  lactate,  next  in  order  is  the  chloride,  the  former  being  from  2  to  3 
times  as  potent  as  the  latter.  The  initial  dose  of  either  is  40  grains  (1.66) 
and  they  afterward  may  be  given  in  20  grain  (1.33)  doses  three  times  a  day. 
The  exhibition  of  the  preparations  of  ergot,  gallic  and  tannic  acid  and  of  the 
lead  salts  is  probably  useless.  Supra-renal  extract  in  doses  of  5  grains  (0.33) 
every  2  or  3  hours  and  the  hypodermatic  administration  of  3I  ounces  (100. o) 
of  a  10  percent,  gelatin  solution  at  110°  F.  (43°  C.)  are  recommended;  the  lat- 
ter, it  is  said,  possesses  haemostatic  properties  and  may  be  given  also  by  mouth. 
The  ordinary  preparation,  which  maybe  found  in  every  kitchen,  may  be  taken 
dissolved  in  water  in  doses  of  2  ounces  (60.0)  every  2  or  3  hours.  Fortu- 
nately pulmonary  haemorrhage  in  itself  is  seldom  fatal  and  tends  sponta- 


l82  THE    INFECTIOUS    DISEASES. 

neously  to  become  checked.  In  cases  where  the  quantity  of  blood  lost  jeopar- 
dizes the  life  of  the  patient  the  limbs  should  be  bandaged  from  the  fingers 
and  toes  toward  the  body;  enteroclyses  and  hypodermatoclyses  of  hot  normal 
saline  solution  should  be  given  to  supply  the  loss.  The  treatment  of  haem- 
optysis by  means  of  inhalation  of  amyl  nitrite  has  recently  been  much  extolled 
and  is  apparently  based  upon  reasonable  principles. 

Sweating  is  often  a  distressing  symptom  and  numerous  drugs  have  been 
employed  in  its  control.  An  excellent  method  of  relieving  the  night  sweats 
which  usually  make  their  appearance  during  the  early  morning  is  to  wake 
the  patient  about  4  A.  M.  and  give  him  a  tumbler  of  warm  milk  containing 
a  little  whiskey;  this  procedure  has  the  additional  advantage  of  supplying 
extra  food.  Aromatic  sulphuric  acid — 15  minims  (i.o)  three  times  a  day — 
camphoric  acid — 15  to  30  grains  (i.o  to  2.0) — given  in  powder  or  in  spirits 

2  or  3  hours  before  the  sweat  is  expected  may  be  prescribed  for  this  symptom 
and  in  excessive  instances  a  hypodermatic  injection  of  ^  (0.016)  grain  of 
morphine  with  yi'S"  of  a  grain  (0.0006)  of  atropine  is  often  effectual.  Mus- 
carine, 5  minims  (0.33)  of  a  one  percent,  solution,  picrotoxin  -g-V  of  a  grain 
(o.ooi),  agaricin,  J  to  J  of  a  grain  (0.008  to  0.016)  and  agaric  acid  in  similar 
dose  have  all  been  recommended. 

The  diarrhoea  of  phthisis,  before  there  is  tuberculous  inflammation  of  the 
intestine,  may  be  controlled  by  bismuth  subsalicylate  or  subnitrate  gr.  xx  (1.33) 

3  times  a  day.  Later  in  the  disease  larger  doses  may  become  necessary. 
If  the  diarrhoea  is  persistent  a  little  opium  may  be  given  and  better 
results  may  follow  the  use  of  bismuth  tetraiodophenolphthaleinate — gr.  v  to 
viii  (0.33  to  0.5) — than  are  obtainable  with  the  commoner  bismuth  salts.  If 
the  diarrhoea  is  the  result  of  tuberculous  involvement  of  the  bowel  it  is 
likely  to  be  persistent  and,  in  addition  to  the  above  means,  irrigations  and 
larger  doses  of  opium  given  with  the  salts  of  lead,  silver  or  zinc,  may  be 
prescribed. 

Tuberculin  has  been  persistently  employed  as  a  therapeutic  agent  by  a 
certain  number  of  observers  but  has  never  been  in  general  use.  It  is  prob- 
ably harmless  and  the  earlier  it  is  employed  and  the  less  general  the 
infection  the  more  likely  will  it  be  to  achieve  benefit.  It  is  said  to  be 
contra-indicated  if  either  fever  or  haemoptysis  is  present.  The  preparation 
employed  should  be  the  tuberculin  residuatum  or  tuberculin  R.  which  is 
potent  to  produce  immunization*and,  if  administered  carefully,  will  cause  no 
reaction.  The  initial  dose  is  15  minims  (1.0)  of  a  solution  of  15  grains 
(1.0)  of  tubercuHn  R.  in  i  pint  (500.0)  of  normal  saHne.  This  solution 
should  be  freshly  prepared — within  24  hours  of  the  time  of  administration. 
A  dose  should  be  injected  into  the  muscular  tissues  of  the  back  every  other 
day.  If  there  results  a  rise  of  temperature  the  succeeding  dose  should  be 
postponed  until  this  has  disappeared.     The  patient,  after  repeated  injections, 


TUBERCULOSIS.  183 

usually  is  able  to  take  much  increased  doses  without  reaction  and  with, 
perhaps,  improvement  in  his  condition. 

In  the  light  of  our  most  recent  knowledge  it  has  become  necessary  to  take 
into  consideration  the  opsonic  power  of  the  blood  when  administering  tuber- 
culin and  other  such  substances  as  a  therapeutic  measure.  The  opsonins 
are  certain  bodies  which  are  contained  in  the  serum  of  normal  blood  and  in 
whose  presence  the  phagocytic  power  of  the  leucocytes  over  pathogenic 
micro-organisms  in  the  blood  stream  is  much  more  potent  than  when  these 
bodies  are  absent.  The  term  opsonic  index  has  been  employed  to  designate 
the  relative  amount  of  opsonins  in  the  circulation,  consequently  a  patient 
whose  blood  contains  them  in  considerable  quantity  is  said  to  possess  a  high 
opsonic  index  and  zdce  versa. 

Tests  have  shown  that  in  the  tuberculous  the  tuberculo-opsonic  index 
is  below  normal.  By  comparing  the  resistance  of  the  opsonic  power  of  a 
patient's  serum  wath  that  of  the  serum  of  normal  individuals  it  has  been 
demonstrated  that  in  all  infectious  processes  times  occur  when  the  patient's 
resistance  is  on  the  increase  and  other  times  when  it  wanes.  In  the  latter 
condition  the  introduction  of  bacterial  vaccines  corresponding  to  the  infective 
micro-organism  present  still  further  lowers  the  opsonic  index  and  the  patient's 
power  of  resistance  is  correspondingly  lessened.  In  view  of  this  fact  the  im- 
munizing substance  should  be  given  during  the  periods  of  high  opsonic  index, 
thus  endeavoring  to  maintain  the  anti-bacterial  power  of  the  blood  at  as  high 
a  level  as  possible  by  observing  the  condition  of  the  opsonic  index  and  regu- 
lating the  time  and  amount  of  dosage  in  accordance  with  its  variations. 
Experimentation  has  shown  that  much  smaller  doses  of  "new  tuberculin" 
than  are  usually  given  produce  the  maximum  immunizing  response  without 
causing  constitutional  disturbance,  and  in  consequence,  a  dosage  equivalent 
to  6"Tji77"(i  to  3-6 ioiT  of  3-  grain  (y  oVir  to  -^\-^  of  a  milligram)  of  tubercle  powder 
are  recommended;  such  doses,  when  given  corresponding  to  the  rises  and 
falls  of  the  opsonic  index  and,  in  connection,  with  means  calculated  to  in- 
crease the  flow  of  blood  and  lymph  through  the  diseased  area,  which  latter 
aid  in  increasing  the  action  of  the  antibodies  upon  the  bacteria  present, 
promise  well  and  seem  to  imply  that  this  method  of  treatment  will  prove  a 
distinct  advance  in  the  combat  against  tuberculous  infection,  particularly 
those  forms  which  affect  the  bones,  joints  and  lymphatic  system.  It  is  also 
quite  clear  that  the  treatment  is  worthy  of  a  careful  trial  in  the  pulmonary 
forms  of  the  disease. 

Serum  treatment,  however,  has  not  as  yet  given  any  results  which  justify 
its  employment  to  the  exclusion  of  other  methods.  Favorable  reports  have 
been  published  upon  the  use  of  the  serums  of  Marmorek  and  Maragliano. 
In  October,  1905,  at  the  International  Tuberculosis  Congress,  von  Behring 
stated  that  he  had  found  a  method  by  the  use  of  which  he  was  able  to  per- 


184  THE    INFECTIOUS    DISEASES. 

manently  immunize  calves  and  that  he  had  succeeded  in  rendering  the  proc- 
ess applicable  to  human  beings.  The  substance  employed  is  an  attenuated 
culture  of  tubercle  bacilli  from  which  certain  injurious  elements  are  removed, 
transforming  it  into  an  amorphous  state,  in  which  condition  it  is  directly 
absorbable  into  the  lymphatics  of  the  organism.  This  method  of  treatment 
is  at  present  sub  judice. 

Apropos  of  the  International  Congress,  Cheinisse  has  recently  been  quoted 
as  saying  that:  "  Serum  therapy  was  the  subject  of  a  great  number  of  com- 
munications, but  the  many  disappointments  which  everyone  has  in  mind 
make  us  skeptical,  and  the  very  multiplicity  of  'serums'  and  'new  tuberculins' 
recommended  in  the  treatment  of  tuberculosis  is  the  best  possible  proof  of 
the  inefficacy  of  every  one  of  these  pretendedly  specific  remedies." 

•  Tuberculosis  of  the  Lymphatic  Glands. 

Synonyms.     Scrofula;  Tuberculous  Adenitis;  King's  Evil. 

.etiology.  Tuberculous  inflammation  of  the  lymph  glands  may  occur 
at  any  age  but  is  most  frequently  met  in  children.  All  catarrhal  affections 
of  the  mucous  membranes  are  predisposing  causes,  the  tubercle  bacilli  which 
find  lodgment  upon  the  diseased  surfaces  being  taken  up  by  the  lymph 
circulation  and  deposited  in  the  adjacent  lymph  ganglia  which  explains  the 
occurrence  of  involvement  of  the  submaxillary  and  cervical  glands  in  in- 
stances of  naso-pharyngeal  or  tonsillar  inflammations,  of  the  bronchial  and 
mediastinal  glands  after  measles  or  whooping  cough  and  of  the  mesenteric 
glands  as  a  result  of  catarrh  of  the  intestines. 

The  specific  cause  of  tuberculous  adenitis  is  the  bacillus  tuberculosis. 

Symptoms.  The  glandular  involvement  may  be  either  general  or  localized. 
The  former  is  rare  but  has  been  observed,  and  particularly  in  the  colored 
race.  The  appearance  resembles  that  of  Hodgkin's  disease,  there  being 
enlargement  of  the  cervical,  submaxillary,  axillary  and  inguinal  glands  with 
pain  and  tenderness,  and  post  mortem  examination  reveals  an  analogous 
state  of  tlie  bronchial,  mesenteric  and  other  internal  lymph  nodes.  There 
is  a  febrile  movement  and  death  may  take  place  from  the  pressure  of  the 
enlarged  ganglia  upon  the  bronchi  or  trachea  or  from  associated  disease. 

Enlargement  of  the  bronchial  glands  is  frequent  in  pulmonary  tuberculosis; 
the  condition  may  be  so  pronounced  as  to  be  recognized  intra  vitam  or  in 
less  marked  instances  is  not  disclosed  until  after  death. 

Local  tuberculous  inflammation  of  the  lymph  glands  is  most  frequent  in 
those  of  the  cervical  region.  It  is  common  in  children,  especially  those  of 
delicate  constitution  and  whose  surroundings  are  unsanitary.  It  may  follow 
the  glandular  enlargements  which  occur  as  a  result  of  tonsillar  enlargement, 
inflammations  of  the  ear  and  pediculosis  or  eczema  of  the  scalp.     The  glands 


TUBERCULOSIS.  1 85 

are  at  first  firm  in  consistency  and  discrete,  later  they  become  matted  together 
into  a  diffuse  mass  and  finally  they  may  soften  and  suppurate,  and  becoming 
adherent  to  the  overlying  skin,  rupture  externally  and  discharge  their  con- 
tents. There  is  an  irregular  febrile  movement,  and  the  patient  is  poorly 
nourished.  In  certain  instances  the  glandular  involvement  extends  to  the 
lymph  nodes  beneath  the  clavicle,  those  of  the  axilla  and  even  to  the  bron- 
chial ganglia;  these  last  tend  to  undergo  caseous  degeneration  rather  than  to 
suppurate.  A  unilateral  inflammation  of  the  axillary  glands  may  be  the 
precursor  of  a  tuberculous  involvement  of  the  pleura  or  lung. 

Involvement  of  the  mesenteric  or  retro-peritoneal  glands  (tabes  mesenterica) 
occurs  as  a  result  of  tuberculous  enteritis  or  primarily  in  simple  catarrhal 
inflammations  of  the  intestine.  The  latter  form  is  especially  common  in 
children.  The  patient  is  emaciated  and  anaemic,  the  abdomen  is  prominent 
and  tympanitic  and  diarrhoea  with  foul-smelling  movements  is  present. 
The  febrile  movement  is  moderate.  Palpation  reveals  the  presence  of  the 
enlarged  glands,  more  rarely  of  tuberculous  deposits  in  the  peritonaeum 
itself.     Death  takes  place  from  intercurrent  disease  or  from  exhaustion. 

In  adults  tabes  mesenterica  is  less  frequent  but  may  occur  primarily  or 
secondary  to  pulmonary  tuberculosis. 

The  tuberculous  glands  of  the  mesentery  and  those  of  the  retroperitonaeal 
region  tend  rather  to  undergo  cheesy  and  calcareous  degeneration  than  to 
suppurate. 

The  diagnosis  of  tuberculous  adenitis  from  Hodgkin's  disease  (pseudo- 
leucaemia)  is  usually  not  difficult.  In  the  former  the  glandular  involvement 
is  less  likely  to  be  general,  the  glands  tend  more  to  become  massed  together, 
to  become  tender  and  to  suppurate,  while  in  the  latter  they  are  more  movable 
and  less  adherent  to  the  surrounding  tissues. 

The  examination  of  the  blood  will  differentiate  tuberculous  glandular 
enlargement  from  that  of  lymphatic  leucaemia  and  the  glands  of  simple  lym- 
phoma are  harder,  more  discrete,  less  tender  and  less  likely  to  become  in- 
flamed; likewise  constitutional  symptoms  are  absent.  Malignant  disease  is 
more  rapid  in  its  progress  and  attended  by  cachexia  and  metastases  if  sarco- 
matous, while  in  carcinoma  we  have  the  primary  growth  to  which  the  glandu- 
lar enlargement  is  secondary. 

The  prognosis  of  cervical  adenitis  is  usually  good,  but  that  of  tabes  mesen- 
terica is  distinctly  bad.  Many  instances  of  acute  tuberculosis  are  said  to 
result  from  the  glandular  form  of  the  disease. 

Treatment  consists  in  the  employment  of  the  general  measures,  hygiene, 
fresh  air,  feeding,  tonics,  etc.,  mentioned  under  the  treatment  of  chronic  pul- 
monary tuberculosis  and  especially  the  administration  of  iron  iodide — 15 
minims  (i.o);  iodine,  locally  in  the  form  of  the  tincture  painted  on,  the 
compound  iodine  ointment  or  as  iodine-vasogen,  seems  to  have  a  certain  in- 


1 86  THE    INFECTIOUS    DISEASES. 

fluence  in  lessening  the  glandular  enlargement.  The  internal  administration 
of  codliver  oil  is  also  to  be  recommended. 

Rather  encouraging  results  have  been  reported  from  the  X-ray  treatment 
of  tuberculous  glands  of  the  neck  and  in  the  opinion  of  certain  observers 
the  prospect  of  success  is  sufficient  to  warrant  the  employment  of  this  means. 
Suppurating  glands  should,  how^ever,  be  incised  and  evacuated;  the  sluggish 
sinuses  which  so  often  persist  may  be  benefited  by  the  application  of  the 
X-ray  which  seems  to  stimulate  the  healing  process. 

The  early  surgical  treatment  of  tuberculous  glands  consists  in  their  removal 
by  dissection,  often  a  difficult  and  prolonged  operation. 

Tuberculosis  of  the  Pleura. 

Tuberculous  involvement  of  the  pleura  occurs  primarily  in  two  chief 
forms:  a,  with  a  sero-fibrinous  exudate  which  is  likely  to  be  blood  tinged; 
b,  with  a  purulent  exudate. 

Either  of  these  may  be  acute  in  course  or  slow  of  evolution.  They  are 
usually  associated  with  tuberculous  infection  of  the  lung  but  in  certain  instances 
may  precede  the  incidence  of  the  latter. 

Secondary  tuberculous  pleurisy  occurs  in  an  acute  and  a  chronic  form. 

The  former  is  the  result  of  the  extension  of  the  inflammation  involving 
the  adjacent  pulmonary  tissue  and  may  be  characterized  by  the  exudation 
of  fibrin,  serum  or  pus.  The  latter  is  characterized  by  the  exudation  of 
fibrinous  exudate  which  becomes  organized  and,  with  the  accompanying  cell 
proliferation,  results  in  marked  pleural  thickening  and  adhesions.  This 
newly  formed  tissue  is  subject  to  tuberculous  infiltration. 

Symptoms.  These  are  identical  with  those  of  the  various  forms  of  non- 
specific pleurisy  (see  p.  656),  with  the  addition  of  the  manifestations  due  to 
the  accompanying  tuberculous  involvement  of  the  lung.  The  physical  signs 
also  differ  in  no  way  from  those  of  simple  pleurisy. 

Treatment  consists  in  the  employment  of  the  methods  applicable  to  pul- 
monary tuberculosis  in  general  and  in  the  evacuation  of  the  accumulated 
fluid  by  aspiration,  if  serous,  or  if  purulent  by  incision  and  the  excision  of 
a  rib  if  necessary. 

Tuberculosis  of  the  Peritonaeum. 

The  peritonseal  membrane  may  be  the  seat  of  tuberculous  disease  which 
manifests  itself  in  the  following  forms: 

a.  A  non-inflammatory  form  in  which  the  miliary  tubercles  are  scattered 
through  the  visceral  and  parietal  layers  of  the  peritonaeum. 

b.  An  inflammatory  type  in  which  the  tubercles  are  associated  with  pro- 
liferation and  adhesions  of  the  two  layers  of  the  membrane  which  may  pro- 


TUBERCULOSIS.  1 87 

ceed  to  obliteration  of  its  cavity,  or  there  is  pronounced  thickening  with 
less  tendency  to  adhesions.  The  mesentery  is  infiltrated,  the  omentum  is 
greatly  thickened  and  contains  deposits  of  tuberculous  tissue  and  similar 
areas  may  occur  in  the  peritonaeal  coat  of  the  intestine  and  that  portion  of  the 
membrane  which  envelops  the  spleen  and  liver;  the  disease  may  occur  with 
hepatic  cirrhosis.  Serous,  bloody  or  purulent  fluid  may  be  present  in  the 
general  peritonaeal  cavity  or  collections  may  be  walled  off  by  adhesions. 

The  disease  may  occur  at  any  age  and  is  especially  frequent  in  the  colored 
race.  Children,  subject  to  catarrhal  affections  of  the  bowel,  and  young  adults 
are  often  affected. 

Symptoms.  Tuberculous  peritonitis  may  exist  without  being  evidenced 
by  any  symptoms  whatever.  In  other  instances  these  may  appear  with  such 
suddenness  as  to  suggest  an  internal  hernia  which  has  become  strangulated; 
in  still  others  the  disease  may  resemble  a  simple  acute  peritonitis  or  enteric 
fever.  The  temperature  in  the  more  acute  instances  is  elevated  but  in  others 
the  febrile  movement  may  be  almost  whoUy  absent.  The  patient's  nutrition 
may  be  but  slightly  impaired.  Abdominal  tenderness  may  or  may  not  be 
present.  Physical  examination  reveals  a  great  variety  of  conditions,  tym- 
panites and  ascites  are  frequent  and  a  stiff,  rigid  abdominal  waU  is  considered 
characteristic  of  the  disease.  Sacculated  collections  of  fluid  walled  by  adhe- 
sions may  be  detected  and  nodular  firm  masses  may  be  demonstrable. 

The  diagnosis  offers  many  difficulties  unless  examination  of  the  other 
organs  and  tissues  reveals  associated  tuberculous  involvement.  The  tuber- 
culin test  may  be  employed  to  clear  up  doubtful  instances. 

Treatment  consists  in  the  employment  of  the  measures  already  suggested 
to  increase  the  patient's  nutrition  and  power  of  resistance.  The  febrile 
movement  may  be  controlled  as  suggested  upon  p.  180.  Diarrhoea  should 
be  controlled  by  intestinal  antiseptics  and  laxatives  may  be  prescribed  when 
indicated.  The  abdominal  pain  may  be  relieved  by  the  local  use  of  the 
tincture  of  iodine  or  the  actual  cautery.  Inunctions  of  ichthyol  4  parts, 
belladonna  extract  2  parts,  mercurial  ointment,  vaseline  and  lanolin  each 
10  parts  or  applications  of  guaiacol  i  to  2  parts,  tincture  of  iodine  15  parts, 
glycerin  20  parts  may  be  employed.  lodine-vasogen  may  also  be  employed 
as  an  inunction.  The  use  of  the  ice  bag  may  assist  in  relieving  the  pain  as 
may  also  rubbing  with  a  mixture  of  chloroform  10  parts,  hyoscyamus  extract 
10  parts,  camphorated  oil  and  lanolin  of  each  25  parts. 

Marked  ascites  should  be  relieved  by  aspiration  and,  in  certain  instances, 
considerable  benefit  has  followed  laparotomy. 

Tuberculosis  of  the  Pericardium. 

Tuberculosis  of  this  structure  occurs  less  frequently  than  similar  affections 
of  the  pleura  and  peritonaeum.     It  may  be  either  primary  or  secondary.     The 


1 88  THE   INFECTIOUS   DISEASES. 

condition  may  be  unrecognized  during  life  and  cause  no  characteristic  symp- 
toms or  it  may  manifest  the  symptoms  of  acute  pericarditis  with  the  effusion 
of  serous,  sero-sanguinolent  or  purulent  fluid.  In  other  instances  the  inflam- 
mation is  characterized  by  adhesions  of  the  pericardium  with  accompanying 
symptoms  of  cardiac  dilatation  and  hypertrophy  and  various  cardiac  mur- 
murs. Acute  tuberculosis  may  result  from  a  primary  tuberculous  involve- 
ment of  the  pericardium. 

Tuberculosis  of  the  Kidney. 

Pathology.  Tuberculosis  of  the  kidney  occurs,  either  associated  with 
general  tuberculous  infection,  in  which  there  are  miliary  tubercles  scattered 
through  the  organ,  or  as  an  affection  characterized  by  areas  of  tuberculous  de- 
generation which  are  prone  to  coalesce  and  to  become  cheesy  and  softened, 
spreading  so  that  the  entire  kidney  is  converted  into  a  caseous  or  purulent 
mass.  Such  a  condition  may  be  secondary  to  tuberculous  prostatitis,  cystitis, 
ureteritis,  or  pyelitis  and  may  spread  also  to  the  epididymis  or  testicle,  ovary 
or  tubes.     One  or  both  organs  may  be  involved. 

Symptoms.  Miliary  tubercles  may  be  present  in  the  kidney  without  caus- 
ing any  especial  symptoms.  In  the  second  type  of  the  disease  the  symptoms 
consist  of  the  passage  of  purulent  urine  which  may  contain  blood  from  time 
to  time.  Micturition  is  usually  frequent  and  there  may  be  dull  lumbar  pain. 
The  patient  usually  loses  flesh  and  strength  and  suffers  from  chilly  feelings 
and  irregular  rises  of  temperature.  Tuberculosis  of  the  lungs  or  of  other 
organs  is  very  frequently  present. 

Palpation  of  the  region  of  the  kidney  causes  pain  and  the  kidney  itself 
may  be  felt.  A  large  tumor  is  seldom  made  out  but  if  the  pelvis  of  the  organ 
is  distended  with  pus  this  may  be  detected  as  a  fluctuating  mass. 

The  urine  contains  pus,  epithelial  cells,  cheesy  masses,  and  at  times,  red  blood 
cells.  Casts  are  seldom  seen  but  albumin  is  present  due  to  the  presence  of  the 
pus  cells.  The  reaction  is  more  usually  acid  than  in  cystitis  and,  upon  sedimen- 
tation by  means  of  the  centrifuge  and  staining  by  the  ordinary  methods,  tubercle 
bacilli  may  be  found,  assuring  the  diagnosis.  If  there  is  doubt  as  to  which 
kidney  is  involved  the  catheterization  of  the  ureters  is  a  simple  matter  to  the 
skilled  hand. 

Treatment,  aside  from  the  employment  of  the  usual  means  to  improve  the 
patient's  general  condition,  is  entirely  surgical.  If  only  one  kidney  is  affected 
it  may  be  removed  in  toto  or  if  but  a  few  tuberculous  nodules  are  found  these 
may  be  excised  and  the  kidney  restored  to  place. 

Tuberculosis  of  the  Pelvis  of  the  Kidney,  Ureter  and  Bladder. 

The  symptoms  of  these  conditions  are  in  no  way  to  be  distinguished,  except 
by  the  detection  of    the  tubercle  bacillus  in  the  urine,  from  simple  inflam- 


TUBERCULOSIS.  1 89 

mations  of  these  structures.  Frequency  of  urination,  pyuria  and  occasional 
haematuria  are  the  principal  manifestations.  Finding  the  tubercle  bacillus 
in  the  urinary  sediment  does  no  more  than  to  prove  that  there  is  tuberculous 
infecftion  of  the  genito-urinary  tract,  it  does  not  distinctly  locate  its  position. 
Cystoscopy  is  of  some  aid  and  by  means  of  this  and  the  searcher  we  should 
be  able  to  eliminate  calculus.  Ureteral  catheterization  which  draws  a  non- 
purulent urine  should  prove  the  freedom  of  the  ureters  from  disease,  but  it  is 
doubtful  if  it  is  advisable  to  risk  infecting  these  structures  by  catheterizing 
them  through  a  diseased  bladder.  Still  this  is  a  matter  for  the  specialist  to 
decide  and  the  procedure  may  be  without  danger  if  the  bladder  is  previously 
washed  and  then  filled  with  an  antiseptic  solution.  A  persistent  cystitis  of 
iodiopathic  origin  is  always  suspicious,  particularly  if  there  is  tuberculous 
involvement  elsewhere  in  the  body. 

Treatment  consists  in  attending  to  the  patient's  general  condition  and  the 
employment  of  the  usual  means,  irrigations,  etc.,  applicable  in  cystitis.  Un- 
fortunately hexamethylene  seems  less  capable  of  destroying  the  tubercle  bacil- 
lus than  other  pathogenic  organisms  in  the  urine. 

Tuberculosis  of  the  Testicles,  Prostate  Gland  and  Seminal  Vesicles. 

Tuberculosis  of  the  testes  and  prostate  gland  occurs  as  a  caseous  degen- 
eration which  seldom  proceeds  to  liquefaction.  Testicular  tuberculosis  is  not 
rare  and  may  be  either  primary  or  secondary  to  tuberculous  disease  of  other 
parts.  It  is  seen  in  children  and  in  adults  and  has  been  observed  in  the 
foetus.  The  epididymis  is  usually  first  invaded  whence  the  affection  spreads 
to  the  testicle  itself ;  the  organ  is  enlarged,  later  becomes  softened  and  ulcerated, 
and  fistulie,  the  walls  of  which  are  infiltrated  with  tuberculous  tissue,  are 
formed.  The  condition  may  be  mistaken  for  syphilis;  both  are  painless  but 
the  latter  affects  primarily  the  body  of  the  testis  in  which  are  situated  irregu- 
lar nodules  of  a  stony  hardness.  In  prostatic  tuberculosis  the  gland  is 
nodular,  the  nodules  being  palpable  upon  rectal  examination,  there  is  vesical 
irritability  and  catheterization  is  painful  and  difficult. 

Treatment  aside  from  the  employment  of  general  measures  is  surgical. 

Tuberculosis  of  the  Ovaries,  Uterus,  and  Fallopian  Tubes. 

Tuberculosis  of  the  tubes  is  the  most  frequent  of  these  affections  and  may 
occur  primarily.  The  diseased  tube  is  enlarged,  infiltrated  and  hard  and 
contains  mucus,  pus  and  caseous  matter.  Abscesses,  followed  by  peritonitis, 
may  occur.     Both  tubes  are  usually  involved. 

Ovarian  tuberculosis  is  usually  secondary  to  tubal  disease;  the  organ  may 
be  infiltrated  with  tubercles  or  caseous  areas,  which  may  form  abscesses, 
may  be  present. 


I  go  THE    INFECTIOUS    DISEASES. 

Uterine  tuberculous  disease  is  rare  and  may  be  primary;  usually,  however, 
it  is  secondary  to  disease  of  the  tubes  or  vagina.  The  wall  of  the  organ  is 
infiltrated  with  tubercles  and  its  mucous  lining  is  thickened.  The  tubercles 
may  undergo  degeneration  which  results  in  ulceration  and  metritis,  the  symp- 
toms of  which  differ  in  no  way  from  uterine  inflammation  due  to  other  causes. 

Tuberculosis  of  the  Mammary  Gland. 

This  afifection  may  occur  in  either  sex  but  is  by  far  more  common  in  women ; 
it  is  most  frequent  between  the  ages  of  40  and  60.  Tubercles  are  deposited 
in  the  glands;  these  degenerate  and  soften,  breaking  through  the  skin  and 
form  suppurating  fistulas,  in  the  walls  and  discharge  of  which  bacilH  may 
be  found.  The  axillary  glands  may  be  enlarged.  Cold  abscesses  of  the 
breast  may  occur.  The  course  of  the  disease  is  usually  protracted,  but  recov- 
ery is  possible  under  proper  constitutional  and  surgical  treatment. 

Tuberculosis  of  the  Heart  and  Blood-vessels. 

Tuberculous  disease  of  the  myocardium  with  tubercles  in  the  substance 
of  the  muscle  may  occur  as  part  of  acute  general  tuberculosis;  caseous  degen- 
eration is  very  infrequent. 

Secondary  tuberculous  endocarditis  due  to  a  mixed  infection  may  be  observed 
in  pulmonary  tuberculosis  and  a  verrucous  endocarditis  with  tubercles  in  the 
valvular  vegetations  has  been  observed. 

Primary  tuberculous  disease  has  been  found  in  the  wall  of  the  aorta  in  rare 
instances  and  the  disease  may  involve,  by  extension,  the  vessels  of  diseased 
tissues;  such  inflammation  weakens  the  vessel  wall  and  perforation  with 
haemorrhage  may  result. 

ACUTE  INFECTIOUS  PNEUMONIA. 

Synonyms.  Croupous  Pneumonia;  Pneumonitis;  Lung  Fever;  Lobar 
Pneumonia;  Fibrinous  Pneumonia. 

Definition.  An  acute,  infectious  inflammation  of  the  lungs,  rendering  the 
involved  portion  of  the  organ  impervious  to  air,  and  characterized  by  a  chill, 
fever,  dyspnoea,  rusty  sputum,  and  prostration. 

.Etiology.  Acute  infectious  pneumonia  is  common  in  all  countries.  It 
occurs  chiefly  in  adults  and  is  most  frequently  seen  during  the  cold  and  damp 
seasons  of  the  year.  Males  are  more  prone  to  the  disease  than  females,  prob- 
ably because  of  the  greater  liability  to  exposure  of  the  former.  Alcoholism, 
debilitated  conditions  and  exposure  to  cold  and  wet  are  predisposing  factors. 
One  attack  is  likely  to  predispose  to  another.  At  times  the  disease  seems  to 
occur  epidemically. 

The  specific  cause  of  the  disease  is  probably  infection  by  either  the  micro- 


ACUTE    INFECTIOUS    PNEUMONIA.  IQI 

COCCUS  lanceolatus  or  diplococcus  of  Frankel,  or  the  bacillus  pneumonias  of  Fried- 
lander  or  both  these  together.  Streptococci,  staphylococci  and  various  other 
micro-organisms  may  be  found  in  pneumonic  sputa  as  the  result  of  a  mixed 
infection.  It  seems  to  be  the  accepted  idea  at  present  that  a  number  of 
different  bacteria  are  capable  of  producing  the  disease. 

Pathology.  In  lobar  pneumonia  the  pathological  anatomy  may  be  di- 
vided into  three  stages. 

a.  Congestion  or  h}-persemia. 

h.  Red  hepatization  or  exudation. 

c.  Gray  hepatization  or  resolution. 

The  lower  lobes  are  most  frequently  affected,  but  involvement  of  the  upper 
lobes  is  not  rare,  and  even  the  whole  of  one  lung  may  become  the  seat  of  the 
morbid  process.  WTien  the  upper  lobes  are  involved  the  disease  is  usually 
of  severe  type. 

During  the  stage  of  congestion  the  lung  is  oedematous  but  not  consolidated 
and  in  the  air  spaces  are  leucocytes,  red  blood  cells,  fibrin  and  epithelium. 
The  vessels  in  the  walls  of  the  alveoli  are  distended.  The  small  bronchi 
undergo  a  like  change,  but  the  larger  bronchi  may  or  not  be  involved.  The 
pleura  as  a  rule  remains  normal.  The  first  stage  usually  lasts  only  a  few 
hours  but  may  continue  throughout  several  days. 

When  the  first  stage  has  reached  its  height  the  air  spaces  and  bronchi  which 
are  the  seat  of  the  inflammation  are  filled  with  its  products  and  the  lung 
becomes  solid,  the  stage  of  red  hepatization.  The  air  vesicles,  spaces  and 
bronchi  are  plugged  with  the  red  blood  cells,  leucocytes  and  fibrin,  but  the 
vessels  of  their  walls  are  not  rendered  impervious.  The  pleura  over  the 
affected  lobe  is  the  seat  of  a  fibrinous  pleurisy.  The  solidified  lobe  is  enlarged 
so  that  it  may  interfere  with  the  action  of  the  other  lobes;  about  25  percent, 
of  the  fatal  instances  die  in  this  stage  from  one  to  ten  days  after  the  onset  of 
the  disease. 

After  the  air  spaces  have  become  filled  and  the  lobe  is  soUdified  the  third 
stage  ensues.  The  inflammatory  material  becomes  gray  in  color  and  soft- 
ened. The  lung  remains  solid.  If  the  patient  recovers  the  exudate  continues 
to  soften  and  disintegrate,  the  stage  of  final  resolution  begins  and  the  lymph 
circulation  carries  off  the  inflammatory  products.  Resolution  should  begin 
when  the  temperature  falls  to  normal  and  should  be  complete  in  a  few  days. 
The  stage  of  transition  between  red  and  gray  hepatization  takes  place  between 
the  second  and  eighteenth  days  of  the  disease.  About  50  percent,  of  the 
fatal  instances  die  in  this  stage. 

If  perfect  recovery  takes  place  the  lung  is  restored  to  its  original  condition. 

Symptoms.  In  a  certain  number  of  patients  there  are  prodromata  such  as 
chilliness,  slight  fever,  general  malaise  and  a  sense  of  oppression,  due  probably 
to  a  lengthened  first  stage  or  period  of  congestion,  but  in  a  great  proportion 


192 


THE   INFECTIOUS    DISEASES. 


of  instances  the  disease  is  ushered  in  by  one  or  more  distinct  chills.  The  tem- 
perature immediately  rises  and  continues  elevated,  with  morning  remissions 
until  defervescence.  Sudden  rises  in  temperature  during  the  course  of  the 
disease  usually  mean  an  extension  of  the  inflammation  or  the  onset  of  a  com- 
plication. When  the  inflammation  affects  the  upper  lobes  the  temperature 
is  likely  to  be  especially  high.  Certain  patients,  especially  old  persons,  show 
very  little  rise  of  temperature,  but  this  does  not  indicate  a  mild  attack. 


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Fig.  7  — Clinical  chart  of  acute  infectious  pneumonia. 


Defervescence  usually  takes  place  by  crisis  on  the  seventh  day,  but  may 
occur  earlier  or  later,  crises  on  the  fifth,  ninth,  or  eleventh  days  being  not  rare. 
In  other  instances  the  defervescence  takes  place  by  lysis — this  being  particu- 
larly likely  to  occur  in  the  pneumonia  complicating  epidemic  influenza — the 
fall  to  normal  extending  over  a  number  of  days. 

The  pulse  is  at  first  full  and  rapid,  later  becoming  weaker  as  the  heart  is 
embarrassed  by  the  obstruction  to  the  passage  of  the  blood  through  the  lungs 
and  by  the  lack  of  oxygen  due  to  the  diminished  respiratory  surface. 


ACUTE    INFECTIOUS    PNEUMONIA.  1 93 

The  respiration  is  rapid  and  shallow  and,  as  the  disease  progresses,  varies 
with  the  amount  of  lung  involved;  the  inspiration  is  short  and  may  be  accom- 
panied by  a  grunting  sound.  The  normal  pulse-respiration  ratio  (4  to  i)  is 
disturbed,  a  ratio  of  two  pulse  beats  to  one  respiration  being  not  infrequent. 
Very  labored  breathing  indicates  large  involvement  of  pulmonary  tissue, 
marked  congestion,  severe  bronchitis,  tendency  to  heart  failure  or  inflam- 
mation of  the  pleura  or  pericardium. 

With  the  onset  there  is  usually  sharp  stabbing  pain  in  the  chest,  increased 
on  coughing  or  inspiration,  which  may  be  due  to  pleuritic  inflammation. 

Cough  may  be  an  early  symptom  or  appear  later  in  the  disease.  In  the 
aged,  especially,  it  may  be  absent.  The  sputum  is  a  blood  stained  muco-pus, 
(the  so-called  "rusty  sputum")  and  very  viscid,  so  much  so  that  it  adheres 
tenaciously  to  the  sides  of  the  containing  vessel.  In  severe  infections  the  sputum 
may  be  thin  and  dark  colored — "prune  juice" — and  large  in  quantity.  As 
resolution  takes  place  the  sputum  becomes  lumpy  and  yellowish  or  greenish. 
In  certain  patients  and  not  infrequently  in  old  persons  there  may  be  no  ex- 
pectoration. 

From  the  onset  the  prostration  is  marked,  the  face  assumes  a  characteristic 
expression  of  anxiety  and  there  is  usually  a  deep  flush  over  the  malar  bones. 
Herpes  labialis  is  not  rare,  and  cyanosis  of  the  lips  and  extremities  may  occur 
when  there  is  marked  obstruction  to  respiration. 

At  the  invasion  there  are  often  nausea  and  vomiting;  the  tongue  is  moist 
and  coated.     In  severe  infections  it  becomes  dry,  brown  and  cracked. 

Headache  and  general  pain  are  common  early  symptoms.  In  severe 
types  of  the  disease  delirium  and  stupor  are  often  seen.  In  alcoholic  patients 
the  infection  is  especially  virulent  and  is  usually  accompanied  by  marked 
delirium,  often  by  delirium  tremens. 

The  urine  is  scanty,  hyperacid  and  diminished  in  quantity.  It  may  con- 
tain albumin  and  casts  and  its  chlorides  are  diminished. 

A  distinct  leucocytosis  is  a  feature  of  this  disease. 

Physical  signs.  Inspection.  First  stage:  Respiratory  movement  is  likely 
to  be  diminished  on  account  of  pain.  Second  stage:  The  normal  side  of 
the  chest  moves  as  in  health,  movement  in  the  affected  side  is  diminished. 
If  both  lower  lobes  are  involved  the  movement  of  the  diaphragm  is  interfered 
with  and  the  respiratory  movement  is  most  apparent  in  the  upper  part  of  the 
chest. 

Palpation.  First  stage:  The  vocal  fremitus  is  slightly  increased.  Second 
stage:  The  vocal  fremitus  is  distinctly  increased  as  a  rule,  rarely  diminished 
or  absent,  probably  due  to  occlusion  of  the  bronchi  by  inflammatory  products. 

Percussion.  First  stage:  Usually  the  note  is  unchanged,  but  it  may  be 
higher  in  pitch,  shorter  in  duration  and  less  distinctly  pulmonary  in  quality. 
Second  stage:  The  note  is  now  more  or  less  dull,  though  it  may  be  flat, 
13 


194  THE    INFECTIOUS    DISEASES. 

tympanitic  or  even  cracked-pot.     If  the  pleural  cavity  contains  fluid,  over 
this  the  note  will  be  flat. 

■Auscultation.  First  stage:  The  respiratory  murmur  may  be  harsh  or 
diminished.  There  may  be  subcrepitant  rales  due  to  the  exudation  into  the 
small  bronchi  and  coarse  rales  with  sibilant  and  sonorous  breathing  due  to 
inflammation  of  the  larger  tubes.  Second  stage:  In  most  patients  both  voice 
and  breathing  over  the  consolidated  lobe  are  bronchial  but  there  may  be 
bronchial  voice  without  bronchial  breathing  or  both  voice  and  breathing 
may  be  absent.  Third  stage:  As  resolution  progresses  the  breathing  becomes 
broncho-vesicular,  and  subcrepitant  and  coarse  rales  in  the  bronchi  are  heard, 
due  to  the  presence  of  the  softened  products  of  the  inflammation.  As  resolu- 
tion continues  normal  vesicular  breathing  becomes  more  apparent  and  the 
percussion  note  approaches  nearer  to  pulmonary  resonance.  The  dulness  is 
the  last  of  the  physical  signs  to  disappear,  it  often  remaining  to  a  slight  extent 
long  after  the  patient  has  recovered. 

Complications.  Of  these  pleurisy  is  the  most  common,  indeed  it  occurs 
whenever  the  pneumonic  process  reaches  the  surface  of  the  lung  and  accord- 
ingly is  so  frequent  as  hardly  to  deserve  the  dignity  of  being  numbered  with 
the  complications.  To  it  is  due  the  severe  pain  of  the  early  stages  and  it  is 
evidenced  by  the  typical  friction  sounds,  which,  however,  may  be  obscured 
by  the  other  physical  signs  present.  Effusion  of  serum  into  the  pleura  is 
not  rare  and  may  go  on  to  empyema,  in  the  pus  of  which  pneumococci  are 
usually  found;  in  infrequent  instances  streptococci  may  be  present.  Purulent 
fluid  is  accompanied  by  a  septic  temperature  with  rigors  and  sweats  and  an 
increased  leucocytosis.  The  physical  signs  are  those  of  fluid  in  the  pleural 
cavity.     If  there  is  doubt  the  use  of  the  aspirating  needle  is  justifiable. 

Pericarditis  is  occasionally  observed  and  is  easily  overlooked;  the  fluid 
is  usually  of  small  quantity  and  serous  in  most  instances;  rarely  it  may  be 
purulent. 

Endocarditis  is  not  very  rare  and  is  of  the  malignant  t)^e.  It  is  especially 
likely  to  occur  if  there  has  been  previous  disease  of  the  heart.  The  physical 
signs  may  be  absent  but  if  the  temperature  persists  and  becomes  of  septic 
character,  if  signs  of  embolism  appear,  or  if  a  cardiac  murmur  develops,  in- 
volvement of  the  heart  should  always  be  suspected. 

Meningitis  is  a  serious  but  not  very  common  complication.  The  most 
usual  time  for  its  appearance  is  while  the  fever  is  at  its  highest  and  it  may 
not  be  recognized,  being  masked  by  the  cerebral  symptoms  of  the  disease. 
Endocarditis  may  be  co-existent  and,  as  a  result  of  this  latter,  there  may  be 
cerebral  embolism  with  its  accompanying  symptoms. 

Complications  which  are  infrequently  met  are  neuritis,  jaundice,  parotitis, 
thrombosis  of  the  peripheral  veins,  usually  those  of  the  leg,  and  peritonitis. 

In  considering  the  complications  of  pneumonia  that  form  of  the  onset  of 


ACUTE    INFECTIOUS    PNEUMONIA.  I95 

the  disease  which  is  marked  by  abdominal  pain  may  be  mentioned.  In 
some  instances  the  symptoms  referable  to  the  lung,  if  present  at  all,  are  wholly 
subordinate  to  severe  pain  in  some  part  of  the  abdomen.  If  this  occurs  in 
the  appendiceal  region  inflammation  of  the  underlying  structure  may  be 
suspected.  The  pain  may  also  be  localized  near  the  navel  or  deep  in  the 
epigastrium  and  suggest  haemorrhage  into  the  pancreas. 

The  diagnosis  is  easy  when  the  physical  signs  are  typical,  pleurisy  with 
effusion  being  more  usually  mistaken  for  lobar  pneumonia  than  any  other 
disease.  In  the  latter  condition,  however,  vocal  fremitus  is  increased,  while 
in  the  former  it  is  absent  and  the  constitutional  symptoms  are  much  less 
severe.  The  aspirating  needle  may  be  used  if  necessary.  In  pneumonia 
there  is  an  increased  leucocytosis,  while  in  pleurisy,  unless  the  fluid  is  puru- 
lent, this  is  not  the  case.  Pneumonic  sputum  usually  contains  the  specific 
micro-organism  of  the  disease  which  will  aid  in  the  differentiation  from  tuber- 
culous conditions. 

The  prognosis  should  be  guarded,  the  outcome  of  the  disease  depending 
in  great  measure  upon  the  age  of  the  patient,  his  previous  condition,  and  upon 
the  extent  of  lung  affected.  Involvement  of  the  upper  lobes  is  considered 
more  serious  than  that  of  the  lower.  Death  usually  takes  place  as  a  result 
of  cardiac  failure  or  of  one  of  the  complications,  meningitis  and  endocarditis 
being  particularly  likely  to  cause  a  fatal  termination.  Under  the  treatment 
to  be  described  the  mortality  should  be  much  lowered. 

Prophylaxis.  Pneumonia  has  recently  become  classified  as  one  of  the 
infectious  diseases,  consequently  all  discharges,  especially  the  sputum,  which 
may  contain  the  contagium,  should  be  treated  as  usual  in  infectious  conditions 
and,  as  an  additional  precaution,  rooms  which  have  been  occupied  by  pneu- 
monia patients  should  receive  proper  fumigation  before  being  again  occupied. 
Cleanliness  on  the  part  of  the  nurse  and  physician  should  also  be  maintained 
as  strictly  as  in  the  handling  of  the  more  virulently  contagious  diseases. 

Treatment.  From  the  onset  of  the  disease  the  patient  should  be  confined 
strictly  to  bed  and  not  allowed  to  rise  for  any  consideration,  sudden  attacks 
of  heart  failure  having  been  known  to  occur  as  a  result  of  so  slight  an  exertion 
as  merely  sitting  up  in  bed.  The  patient  should  wear  a  flannel  night  gown 
or  shirt  which  should  open  behind  to  facilitate  examination  of  the  chest. 
The  room  should  be  large,  light,  well  ventilated  and  kept  at  a  temperature 
of  from  65°  to  70°  F.  (18.3°  to  21.1°  C).  At  the  onset  of  the  disease  calomel 
should  be  administered,  followed  by  a  saline,  and  throughout  the  infection  the 
bowels  should  be  kept  freely  open. 

Medicinal  treatment  should  be  directed  i,  toward  limiting  the  infection; 
2,  toward  overcoming  the  mechanical  disadvantages;  3,  toward  the  elimi- 
nation of  the  products  of  the  bacterial  cause  of  the  disease. 

In  the  exhibition  of  creosote  carbonate  we  have  a  means  of  limiting  the 


196  THE    INFECTIOUS    DISEASES. 

infection  as  proven  by  the  statistics  of  various  authorities.  This  drug  cuts 
short  or  aborts  a  large  percentage  of  instances,  mitigates  almost  all  the  rest,  and 
in  a  small  proportion  of  patients  no  result  is  obtained.  Certainly  if  the  early 
appearance  of  the  crisis  is  any  indication  of  the  value  of  the  treatment  this 
remedy  is  deserving  of  a  trial.  Unlike  creosote  itself  the  carbonate  is  not 
disturbing  to  the  kidneys  or  stomach  even  when  administered  for  considerable 
periods  of  time.  The  usual  dose  is  from  two  to  four  drachms  (8.0  to  16.0) 
daily,  the  dose  interval  being  six  hours,  but  to  a  vigorous  man  as  much  as 
one-half  a  drachm  (2.0)  every  two  hours  may  be  given.  It  may  be  given  in 
milk,  sherry,  or  pure.  The  medication  should  be  continued  until  the  tem- 
perature has  remained  normal  for  four  or  five  days,  but  when  the  febrile 
stage  is  passed  the  dosage  may  be  reduced  one-half. 

The  mechanical  obstruction  to  the  circulation  is  best  combated  by  the 
use  of  nitrites  (glyceryl  nitrate  or  sodium  nitrite).  These  reHeve  the  high 
tension  in  the  pulmonary  circulation  to  a  slight  extent  and  that, of  the  systemic 
circulation  markedly. 

Of  late  erythrol  tetranitrate  in  doses  of  one-half  grain  (0.032)  every  four 
to  six  hours  has  given  more  even  and  controllable  effects  than  the  evanescent 
glyceryl  nitrate  or  the  uncertain  sodium  nitrate.  Hypodermatic  stimulation 
by  strychnine  nitrate  or  sulphate  in  doses  of  from  one-fiftieth  (0.0012)  even 
to  one-tenth  of  a  grain  (0.006)  every  four  to  six  hours  may  be  employed  as 
indicated,  and  continued  until  the  desired  result  is  obtained.  The  heart 
should  be  carefully  watched  for  signs  of  dilatation  and  when  these — weak- 
ness of  the  pulse  and  of  the  second  pulmonic  sound — appear  the  stimu- 
lation is  necessary.  Care  should  be  taken  not  to  mistake  the  appearance  of 
defervescence  for  threatened  cardiac  weakness,  for  at  the  crisis  the  second 
pulmonic  sound  loses  its  booming  character  on  account  of  the  lessening  of  the 
tension  in  the  pulmonary  circulation  consequent  upon  beginning  resolution. 

Alcohol  as  a  stimulant  should  usually  be  confined  to  patients  accustomed 
while  in  health  to  it.  The  amount  given  should  be  gauged  by  the  patient's 
condition  and  may  even  reach  a  quart  (Htre)  per  day.  Ammonium  carbonate 
in  10  grain  (0.66)  doses,  in  2  ounces  (60.0)  of  milk  every  2  hours,  replaces  the 
strychnine  in  the  aged.  Excellent  results  are  claimed  for  and  obtained  by 
veratrum  viride  in  the  very  early  stages  of  the  disease  occurring  in  young 
or  even  middle-aged  individuals,  but  unfortunate  results  are  quite  as  fre- 
quent as  successes  with  this  drug  and  it  is  to  be  employed  exceptionally 
only.  To  bleeding  the  same  remarks,  though  perhaps,  more  stringently, 
will  apply.  It  is  also  well  known  that  venesection  does  not  give  as  good 
results  in  pneumonia  as  in  cyanosis  with  dilated  right  heart  due  to  other 
causes.  This  observation  leads  us  to  question  as  to  how  much  the  pressure 
in  the  pulmonary  artery  is  raised  by  extensive  pulmonary  consolidation. 

Toward  elimination  of  the  products  of  the  bacteria  causing  the  disease  we 


ACUTE    INFECTIOUS    PNEUMONIA.  1 97 

can  do  much  by  means  of  high  rectal  irrigations  of  normal  (0.9  percent.)  saline 
solution,  one  gallon  (4  litres)  at  112°  F.  (44.4°  C.)  given  twice  daily.  It  is 
particularly  potent  in  patients  with  complicating  renal  disease.  It  is  a  most 
valuable  method  of  provoking  diuresis,  stimulating  the  heart,  cleaning  the 
large  intestine  and,  to  a  less  extent,  producing  diaphoresis.  One-sixth  of  a 
grain  (o.oii)  of  calomel  every  hour  for  six  doses,  with  saline  laxatives  suffi- 
cient to  empty  the  bowels  completely  and  keep  them  open  afterward,  with 
from  three  to  six  grains  (0.2  to  0.4)  of  zinc  phenolsulphonate  every  two  to 
four  hours,  may  be  administered  with  benefit.  When  the  odor  has  disap- 
peared from  the  stools  the  zinc  salt  should  be  given  in  doses  just  sufficient  to 
prevent  foetor  and,  if  constipation  occurs,  a  second  course  of  calomel  followed 
by  a  saline  may  be  prescribed  until  the  stools  are  odorless.  It  is  true,  how- 
ever, that  under  the  creosote  treatment  tympanites  is  rare  and  the  necessity 
for  intestinal  disinfection  is  much  lessened. 

Oxygen  is  of  value  if  the  respiratory  surface  is  much  decreased  and  its 
inhalation  is  advocated  by  many  as  a  valuable  ciu-ative  measure.  It  gives 
ease  to  the  patient,  relieves  the  cyanosis,  the  faihng  heart  and  the  laboring 
respiration,  and  may  induce  sleep.  The  best  method  of  administering  it 
is  to  arrange  a  funnel  attached  to  the  container  in  front  of  the  patient's  nose 
and  mouth.  It  must  be  given  for  considerable  periods  at  a  time  and  to  some 
patients  incessantly.  Certain  observers  advocate  its  intermittent  use  from  the 
beginning  of  the  disease  on  the  ground  that  it  is  likely  to  ward  off  respiratory 
failure. 

Expectorants  when  necessary  may  be  prescribed,  the  preference  to  be  given 
to  apomorphine  hydrochloride  yi  oi  a.  grain  (0.002)  every  4  hours. 

Acute  infectious  pneumonia  in  the  aged  is  a  very  serious  disease  on  account 
of  the  tendency  of  old  persons  to  heart  weakness  and  pulmonary  hypostasis. 
Free  stimulation  is  likely  to  be  necessary  and  the  patient  should  be  rolled 
from  one  side  to  the  other  several  times  a  day.  It  is  the  author's  custom, 
when  the  stomach  will  bear  the  drug,  to  administer  10  grains  (0.66)  of  ammo- 
nium carbonate  in  2  ounces  (60.0)  of  milk  3  times  a  day  to  these  patients. 

Local  applications  which  interfere  with  the  patient's  comfort  are  to  be 
avoided.  A  pneumonia  jacket  of  cotton  batting  overlaid  by  oiled-silk  is 
pleasing  to  many  and,  if  pleuritic  pain  be  present,  a  layer  of  cataplasma  kaolini 
spread  on  the  chest  and  covered  with  layers  from  a  roller  bandage  often  affords 
relief.  A  liniment  of  equal  parts  of  menthol,  hydrated  chloral  and  camphor 
well  rubbed  in  at  the  seat  of  the  pain  is  also  useful.  In  very  marked  pleuritic 
pain  hypodermatic  injections  of  morphine  may  become  necessary. 

The  headache  and  deHrium  may  be  mitigated  by  the  use  of  the  ice  helmet. 

Treatment  by  means  of  an  antitoxin  has  been  extensively  attempted  but 
the  results,  as  a  whole,  fail  to  carry  conviction.  An  efficient  serum,  or  one 
which  will  shorten  the  disease,  has  not  yet  been  elaborated  but  in  the  opinions 


198  THE    INFECTIOUS    DISEASES. 

of  certain  observers  the  serums  at  present  available  have  a  limited  use.  The 
results  so  far  attained  by  the  use  of  treatment  by  antitoxin  have  modified 
the  mortality  to  scarcely  sufficient  degree  to  v^rarrant  its  universal  employ- 
ment. The  serums  thus  far  elaborated  possess  no  antitoxic  quahties  and 
that  they  possess  anti-infectious  properties  has  yet  to  be  proved.  Notwith- 
standing the  discouraging  results  attained  up  to  this  time  in  the  attempt  to 
discover  a  potent  treatment  for  pneumonia  along  this  line,  further  research 
is  to  be  encouraged. 

Diet.  Milk,  preferably  peptonized  or  diluted  with  Vichy  or  lime  water, 
or  the  fermented  milks,  kumyss  or  matzoon,  should  be  our  chief  reliance. 
The  preparations  of  the  meats  in  the  form  of  extracts  may  be  allowed. 

Taking  all  into  consideration  the  treatment  of  pneumonia  is  especially 
satisfactory.  In  fine  we  should  rely  upon:  i.  The  continuous,  persistent 
and  generous  administration  of  creosote  carbonate.  2.  Careful  adjustment 
of  mechanical  conditions.  3.  Thorough  evacuation  of  toxins  by  all  possible 
means.  4.  Temporary  supplemental  oxygen  by  inhalation.  5.  Liquid 
diet  until  all  physical  signs  disappear. 

BRONCHO-PNEUMONIA. 

Synonyms.  Catarrhal  Pneumonia;  Capillary  Bronchitis;  Lobular  Pneu- 
monia. 

Definition.  A  disease  of  the  lungs  caused  by  microbic  infection  and  char- 
acterized by  areas  of  consolidation  of  varying  size  scattered  through  the  lung, 
each  surrounding  a  bronchus. 

.Etiology.  It  is  this  form  of  pneumonia  which  occurs  most  frequently 
in  children;  it  is  also  prone  to  attack  the  aged. 

The  disease  may  occur  primarily  as  a  result  of  exposure;  especially  is  it 
predisposed  to  by  catarrhal  affections  of  the  air  passages  and  particularly  by 
the  presence  of  adenoids  and  enlarged  tonsils. 

Secondarily  broncho-pneumonia  occurs  as  a  complication  of  the  acute  infec- 
tious diseases  particularly  those  to  which  children  are  prone,  measles,  scarlet 
fever,  diphtheria  and  whooping  cough,  which  accounts  for  the  numerous  in- 
stances of  the  disease  during  the  early  years  of  life.  It  may  occur  secondary  to 
bronchitis  in  adults  as  well  as  in  infants  and,  in  the  former,  especially  in  old 
age,  it  may  complicate  the  infectious  diseases  and  various  chronic  affections 
such  as  nephritis  and  endocarditis. 

The  so-called  foreign-body  or  inhalation  pneumonia  is  a  variety  of  broncho- 
pneumonia; this  type  of  the  disease  is  caused  as  follows:  In  comatose  states 
or  when  for  any  other  reason  the  sensibility  of  the  glottis  is  impaired,  particles 
of  food  or  drink  may  pass  into  the  trachea  and  thence  into  the  smaller 
bronchi  where  they  cause  irritation,  subsequent  inflammation  and  even  sup- 


BRONCHO-PNEUMONIA.  1 99 

puration  and  gangrene.  Inhalation  pneumonia  may  follow  operations  upon 
the  pharynx  or  larynx,  and  the  inhalation  of  particles  of  blood  clot  raised 
during  haemoptyses;  it  may  occur  in  individuals  whose  occupations  necessi- 
tate the  respiration  of  air  impregnated  with  dust,  such  as  coal  miners,  stone- 
cutters, etc. 

Poor  hygienic  surroundings  and  poor  sanitary  conditions  predispose  to  the 
incidence  of  broncho- pneumonia. 

The  micro-organisms  most  often  associated  with  broncho-pneumonia  are 
the  streptococcus  pyogenes,  staphylococcus  alhus  and  aureus,  the  pneumobac- 
illus  and  the  micrococcus  lanceolatus.  The  diphtheria  bacillus  also  may  be 
found  if  the  affection  is  secondary  to  diphtheria.  Mixed  infections  are 
the  rule. 

Pathology.  The  surface  of  the  lung,  if  the  areas  of  consolidation  reach 
the  surface  of  the  organ,  shows  prominences,  over  which  the  pleura  may  be 
the  seat  of  a  fibrinous  exudation,  and  depressions  of  darker  color;  the  latter 
representing  collapsed  lung  which  may,  however,  be  re- inflated.  Other 
parts  of  the  lung  may  be  the  seat  of  a  compensatory  emphysema.  The  pro- 
jecting areas  represent  consolidation.  These  are  firm  and  may  be  small, 
consisting  of  a  zone  of  inflamed  tissue  surrounding  a  single  bronchus,  or  large 
as  a  result  of  the  coalescence  of  several  such  areas.  Cross  section  of  the 
consolidated  zones  reveals  a  central  spot  of  lighter  color  from  which  pus  may 
be  expressed;  this  is  the  bronchus  the  lining  of  which  is  the  seat  of  an  exuda- 
tive inflammation.  Microscopically  the  exudate  in  the  consolidated  portions 
of  lung  is  seen  to  be  composed  of  fibrin,  pus  and  red  blood  cells  and  epithe- 
lium. The  bronchial  mucous  membrane  is  swollen  and  infiltrated  with 
leucocytes;  its  lumen  is  blocked  by  an  exudate  of  mucus,  pus  and  exfoliated 
epithelial  cells.  The  air  cells  adjacent  to  the  areas  of  consolidation  are  dilated 
and  emphysematous.  In  adults  a  later  stage  of  the  consolidation  may  resem- 
ble in  appearance  the  gray  hepatization  of  lobar  pneumonia  and  it  may 
finally  undergo  permanent  sclerosis.  In  inhalation  pneumonia  the  inflam- 
matory process  is  more  pronounced  and  may  be  followed  by  abscess  formation 
or  gangrene. 

The  pneumonic  process  may  terminate  in  resolution,  chronic  interstitial 
broncho-pneumonia  (cirrhosis  of  the  lung),  suppuration  or  gangrene,  or  a 
secondary  infection  with  the  tubercle  bacillus  may  take  place,  leading  to 
acute  or  chronic  pulmonary  tuberculosis. 

Symptoms.  In  the  primary  form  of  the  disease  the  onset  may  be  sudden, 
with  a  chill,  which  may  be  unnoticed,  or  a  convulsion,  but  more  commonly 
the  invasion  is  gradual  with  cough,  increasing  dyspnoea  and  a  rise  of  tem- 
perature. In  the  secondary  type  we  usually  have  the  symptoms  of  the  primary 
affection  and  a  cough  to  which  a  febrile  movement  is  added — ioi°  to  104°  F. 
(38.5°  to  40°  C).     The  cough  becomes  more  marked,  the  pulse  rapid  and  the 


200  THE    INFECTIOUS    DISEASES. 

respiration  increased — 46  to  60  or  even  higher — there  is  dyspnoea  and  often 
cyanosis  of  the  face  and  extremities.  As  the  disease  progresses  the  cough 
becomes  less  frequent  but  the  pulse  and  respiration  remain  accelerated,  the 
former  growing  gradually  weaker,  until  death  occurs  from  failure  of  the  right 
heart.  In  more  favorable  instances  after  a  few  days  the  symptoms  abate 
and  recovery  takes  place.     Convulsions  may  occur  as  a  late  symptom. 

In  adults  the  onset  varies  but  is  usually  gradual,  with  cough,  rapid  pulse, 
dyspnoea  and  fever.  The  diagnosis  is  usually  impossible  without  physical 
examination.  In  inhalation  pneumonia  the  invasion  is  prolonged  and  the 
development  of  the  symptoms  slow. 

Physical  Signs.  In  certain  instances  the  areas  of  consolidation  may  be  too 
small  to  give  distinctive  physical  signs.  Here  at  fkst  we  may  have  the  coarse 
rales  of  a  general  bronchitis,  and  over  a  certain  part  of  the  lungs,  usually 
in  one  of  the  lower  lobes  posteriorly,  coarse  sonorous  and  finer  sibilant  rales 
are  heard  which  are  soon  replaced  by  fine  moist  subcrepitant  rales  with  an 
enfeebled  and  high  pitched  respiratory  murmur.  Larger  areas  of  consol- 
idation give  the  moist  subcrepitant  rales  which,  directly  over  the  solidified 
portion  of  the  lung,  are  louder  and  seem  closer  to  the  ear.  Here  the  respira- 
tion is  higher  pitched  and  broncho-vesicular.  The  voice  is  also  of  increased 
resonance.  The  percussion  note  and  vocal  fremitus  are  often  unchanged 
but,  if  the  consolidated  zones  are  of  considerable  size,  slight  dulness  may  be 
apparent  and  perhaps  slight  increase  in  fremitus.  At  the  center  of  the  solid 
area  the  voice  and  breathing  are  bronchial,  becoming  less  typically  so  as  the 
margin  of  the  consolidation  is  approached.  The  rales  are  often  absent  over 
the  point  of  maximum  consolidation  but  become  more  frequent  at  a  distance 
from  this  situation.  When  resolution  begins  the  bronchial  voice  and  breath- 
ing are  the  first  to  disappear;  rales  may  persist  for  several  weeks.  It  must 
be  remembered  that  frequently  ordinary  respiration  will  not  suffice  to  render 
the  physical  signs  perceptible;  the  child  must  be  made  to  take  deep  respira- 
tions or  to  cry. 

In  old  persons  the  signs  are  analogous  to  those  in  children.  When  the 
consolidation  involves  but  a  small  portion  of  the  pulmonary  tissue  there  m.ay 
be  no  sign  but  fine  moist  rales.  In  larger  areas  of  solidification  the  signs  are 
more  marked. 

The  diagnosis  in  children  may  be  easily  made,  especially  in  the  secondary 
instances  of  the  disease,  for  a  cough,  fever,  rapid  pulse  and  respiration,  with 
the  occurrence  of  fine  moist  rales  over  a  portion  of  the  lungs  signify  bron- 
cho-pneumonia and  nothing  else,  but  if  the  consolidated  area  is  large  and 
the  physical  signs  bear  a  close  resemblance  to  those  of  acute  infectious  pneu- 
monia the  differentiation  from  the  latter  affection  may  be  difficult.  In  lobar 
pneumonia  the  temperature  is  likely  to  be  persistently  high  while  in  bron- 
cho-pneumonia it  is  frequently  remittent. 


BRONCHO-PNEUMONIA.  20I 

The  prognosis  is  always  serious  in  children,  but  depends  to  a  great  extent 
upon  the  previous  condition  and  upon  the  primary  disease  if  the  pneumonia 
is  secondary.  In  private  the  patient's  chances  are  far  better  than  in  hospital 
practice.  Young  infants  are  more  likely  to  perish  than  those  over  i  year  of 
age.  Patients  who  take  nourishment  and  assimilate  well  are  likely  to 
recover,  but  those  who  suffer  from  digestive  disturbances  less  commonly 
do  well.  Convulsions  in  the  latter  part  of  the  disease  are  a  serious  symptom. 
Even  in  children  the  disease  may  go  on  to  pulmonary  tuberculosis. 

In  severe  infections  death  may  take  place  within  24  hours;  in  favorable 
instances  the  disease  lasts  a  week  or  10  days  and  is  followed  by  a  convales- 
cent period  of  similar  duration. 

Treatment.  Prophylaxis  consists  in  careful  treatment  and  care  for  all 
instances  of  catarrhal  affections  of  the  upper  or  lower  air  passages,  the  removal 
of  adenoids  and  enlarged  tonsils,  careful  nursing  during  and  avoidance  of 
exposure  after  all  acute  infectious  diseases  and  the  isolation  of  broncho- 
pneumonia patients,  when  the  disease  breaks  out  in  hospitals. 

The  patient  should  be  kept  in  bed,  unless  he  is  small  enough  to  be  held  in 
the  nurse's  arms  for  some  time  each  day,  in  a  thoroughly  ventilated  apartment 
— one  with  an  open  fire-place  is  best — and  it  is  wise  to  remove  him  to  another 
room  at  least  twice  during  the  24  hours,  while  the  sick-room  is  aired.  The 
food  should  be  of  liquids  entirely  and  chiefly  of  milk.  If  the  child  is  receiving 
a  modified  milk  mixture  it  is  well  to  dilute  this  with  equal  parts  of  water  during 
the  acuity  of  the  illness. 

At  the  onset  the  bowels  should  be  opened  by  calomel — yV  to  J  of  a  grain 
(0.006  to  0.016)  of  calomel  at  ^  hour  intervals  until  6  doses  have  been 
taken. 

Poultices  or  blisters  should  not  be  applied,  the  application,  however,  of  a 
mild  mustard  paste,  of  a  strength  of  i  part  mustard  to  6  of  flour  mixed  with 
lukewarm  water  and  put  on  while  warm,  is  advised.  This  should  be  large 
enough  to  cover  the  whole  chest,  should  be  applied  every  2  to  4  hours  and 
allowed  to  remain  in  place  until  the  skin  is  well  reddened,  not  blistered.  If 
fever  is  absent  the  pneumonia  jacket  of  cotton  batting  laid  between  muslin 
and  oiled-silk,  the  former  being  placed  next  the  skin  may  be  worn,  but  if  the 
temperature  is  elevated  this  is  best  omitted. 

The  cough  may  be  relieved  and  the  bronchial  secretion  rendered  less  ten- 
acious by  steam  inhalations  which  are  given  by  means  of  a  croup  kettle,  the 
spout  of  which  is  passed  into  a  tent  made  of  blankets  and  arranged  over  the 
crib.  Either  water  alone  or  lime  water  may  be  employed  in  the  early  stages; 
later  creosote,  eucalyptol  or  compound  tincture  of  benzoin  may  be  added. 
Each  inhalation  should  last  about  a  quarter  of  an  hour  and  these  may  be 
given  as  many  as  10  times  daily,  depending  upon  the  patient's  condition. 

It  is  very  important  that  the  digestion  remain  undisturbed,  consequently 


202  THE    INFECTIOUS    DISEASES. 

the  less  medication  given  by  mouth  the  better;  however,  we  often  prescribe 
creosote  carbonate  with  benefit.  A  child  of  2  years  may  take  from  2  to  3 
minims  in  a  spoonful  of  milk  every  3  or  4  hours.  If  expectorants  are  deemed 
necessary,  and  this  is  seldom  the  case,  to  older  children  in  the  first  stage 
we  may  give  antimony  and  ipecac  in  minute  doses  and  later  one  of  the 
stimulating  expectorants.  The  following  prescriptions  may  be  useful:  I^, 
vini  ipecacuanhae  5ij  (8.0),  vini  antimonii  3j  (4.0),  vini  xerici  5iij  (12.0). 
Misce  et  Signa,  10  drops  every  2  hours  for  a  child  2  years  old.  I^,  ammonii 
chloridi  gr.  x  (0.66),  spiritus  camphorae  3j  (4.0),  spiritus  setheris  nitrosi  3ij 
(8.0),  S)Tupi  tolutani  oiij  (12.0),  aquae  gaultheriae,  aquae  destillatae,  aa  q.  s.  ad 
5iij  (90.0).  Misce  et  Signa,  one  teaspoonful  every  hour  for  a  child  2  years  old. 
Too  much  stress  cannot  be  laid  upon  the  danger  of  the  indiscriminate  admin- 
istration of  expectorants  and  emetics  to  children.  Emetics  are  allowable 
only  when  the  secretion  is  profuse  and  the  cough  insufficient  to  relieve  the 
bronchial  tubes;  here  we  may  employ  the  syrup  of  ipecac  in  dose  of  i  drachm 
(4.0)  for  a  child  of  2  years.  Emetics  are  strictly  contra-indicated  in  severe 
infections  with  depressed  circulation. 

If  the  cough  is  distressing  small  doses  of  pulvis  ipecacuanhas  et  opii  with 
the  addition  of  acetphenetidine  (phenacetine)  if  there  is  high  temperature 
and  restlessness — ^  a  grain  (0.03)  of  the  former  and  i  grain  (0.065)  of  the 
latter — may  be  given  to  a  child  of  2  years.  To  younger  children  these  drugs 
should  be  administered  with  great  care  on  account  of  their  depressing  influence 
upon  the  heart  and  respiration  and  the  constipating  effect  of  the  opium. 
Heroine  is  useful  in  older  children  to  relieve  the  cough,  the  dose  for  a  child 
of  5  years  being  from  y^'^  to  er  of  a  grain  (0.0006  to  o.ooi). 

Tincture  of  aconite  in  doses  of  2  minims  (0.13)  may  be  given  in  the  early 
stages  of  the  disease  every  two  hours,  when  the  pulse  is  full  and  bounding, 
until  its  effect  is  noted. 

Stimulation  is  necessary  as  soon  as  there  is  any  evidence  of  circulatory 
weakness  and  here  our  chief  dependence  must  be  placed  upon  alcohol,  in 
the  form  of  brandy  or  whiskey,  and  strychnine;  20  drops  (1.33)  of  either 
of  the  two  former  may  be  given  to  a  patient  of  from  i  to  2  years  old  every 
2  hours.  It  should  be  well  diluted  with  water  and  the  dosage  may  be  increased 
if  necessary.  The  dose  of  strychnine  for  a  child  of  2  years  is  ^iij-  of  a  grain 
(0.0003)  every  2  or  3  hours. 

Attacks  of  respiratory  failure  should  be  combated  by  full  doses  of  strych- 
nine and  atropine  and  the  administration  of  oxygen  inhalations.  The  child 
may  be  made  to  cry,  which  will  cause  fuller  inspirations  of  air  and  freer  oxygen- 
ation of  the  blood,  by  continued  spanking  or  the  employment  of  alternate 
hot  and  cold  applications  of  water  to  the  chest;  a  hot  mustard  bath  is  useful 
in  collapse.     The  repetition  of  these  procedures  is  often  necessary. 

Nervous  symptoms,  restlessness,  sleeplessness,  etc.,  may  be  relieved  by  small 


*     CHRONIC    INTERSTITIAL    PNEUMONIA.  203 

doses  of  acetphenetidine  and  if  the  fever  reaches  105°  F.  (40.5°  C.)  or  over, 
cold  sponging  is  useful. 

During  convalescence  tonics,  especially  codliver  oil  and  the  syrup  of  iron 
iodide,  should  be  prescribed  and  in  instances  of  persistent  cough  small  doses 
of  creosote  carbonate  are  very  useful.  It  may  be  necessary  to  complete 
recovery  to  prescribe  a  change  of  climate. 

The  treatment  of  the  broncho-pneumonia  of  adults  is  essentially  the  same 
as  that  of  acute  infectious  pneumonia  (see  p.  195.)  Inhalation  pneumonia 
is  usually  secondary  to  other-  serious  disease  and  while  the  general  treatment 
is  that  of  broncho-pneumonia,  the  results  are  not  all  that  might  be  desired. 

CHRONIC  INTERSTITIAL  PNEUMONIA. 

Synonyms.     Cirrhosis  of  the  Lung;  Sclerosis  of  the  Lung. 

Definition.  A  chronic  inflammatory  affection  of  the  lung  characterized 
by  an  over-growth  of  fibrous  tissue  which  replaces  the  normal  pulmonary 
parenchyma.  This  interstitial  change  may  be  either  local  or  diffuse,  accord- 
ing as  to  whether  it  involves  small  or  large  areas  of  the  lung  tissue. 

.etiology.  This  disease  is  chiefly  a  secondary  affection  and  occurs  with 
nearly  all  chronic  pulmonary  inflammations.  In  tuberculosis,  the  fibroid 
phthisis  (q.v.)  which  at  times  results,  is  a  form  of  interstitial  pneumonia. 
It  also  frequently  follows  a  broncho-pneumonia  even  in  children,  very  rarely 
it  succeeds  acute  infectious  pneumonia.  Chronic  interstitial  pheumonia 
occurs  as  a  result  of  the  inhalation  of  dust  by  those  whose  occupations  neces- 
sitate working  in  a  dust-laden  atmosphere.  It  may  be  caused  by  any  of  the 
tumors  and  cysts  which  may  involve  the  lung  and  may  be  induced  by  pul- 
monary abscess.  Chronic  fibrinous  pleurisy  or  pleurisy  with  effusion  may  so 
compress  the  lung  as  to  lead  to  fibroid  change  and  the  same  degeneration 
follows  compression  by  aneurysmal  tumors  and  the  irritation  caused  by  the 
presence  of  a  foreign  body.  Microbic  infection,  in  addition  to  mechanical  in- 
fluences, bears  a  distinct  relation  to  the  production  of  interstitial  pneumonia. 

Pathology.  The  affected  lung  is  shrunken  and  much  retracted  within 
the  thoracic  cavity  and  displacement  of  the  heart  is  usually  observed  if  the 
affection  involves  the  left  lung;  pleuritic  adhesions  are  common.  On  section 
the  lung  is  dense  and  firm  and  of  grayish  color  due  to  the  presence  of  the 
fibrous  tissue  and  through  this  the  bronchi  and  blood-vessels  make  their 
course;  the  former  may  be  the  seat  of  bronchiectatic  dilatations,  the  latter  of 
a  sclerotic  inflammation.  The  pulmonary  alveoli  are  to  a  greater  or  less 
extent  encroached  upon  by  the  over-growth  of  interstitial  tissue.  In  the 
tuberculous  type  of  the  disease  there  may  be  miliary  tubercles  or  cav- 
ity formation.  There  is  compensatory  emphysema  of  the  uninvolved 
lung    and    the    right    ventricle    of    the    heart    is    hypertrophied    and   per- 


204  THE    INFECTIOUS    DISEASES. 

haps  dilated.  Microscopically  the  fibrous  infiltration  begins  in  the  wall 
of  the  bronchi  and  spreads  thence  to  the  alveolar  walls,  the  entire  lobule 
ultimately  becoming  fibrous  and  firm.  If  the  interstitial  pneumonia  fol- 
lows an  acute  infectious  pneumonia  the  exudate  in  the  air  vesicles  becomes 
organized  into  fibrous  tissue  and  a  connective  tissue  change  takes  place  in 
the  alveolar  walls  as  well. 

Symptoms.  Of  these  the  most  constant  is  cough  which  is  much  more 
distressing  at  some  times  than  at  others;  it  may  be  paroxysmal.  With  the 
cough  there  is  muco-purulent  expectoration;  when  bronchiectatic  cavities 
are  present  considerable  quantities  of  sputum  may  be  raised  from  time  to 
time,  this  manifestation  occurring  when  the  cavity  is  emptied;  this  sputum 
may  be  foetid.  Haemoptysis  may  take  place.  Dyspnoea  is  a  frequent  symp- 
tom; it  is  seldom  of  very  distressing  character.  The  course  of  the  disease  is 
chronic  and  may  be  protracted  for  years,  but  the  patient  is  seldom  prevented 
from  doing  light  work. 

Physical  Signs.  Inspection  reveals  a  retraction  of  the  thorax  upon  the 
affected  side  and  a  restriction  in  its  respiratory  movement;  the  unaffected 
side  is  more  prominent  and  of  greater  circumference  than  normal  as  a  result 
of  compensatory  emphysema.  The  apical  impulse  of  the  heart  may  be 
displaced.  Vocal  fremitus  is  diminished  if  the  pleura  is  thickened.  Upon 
percussion  there  is  dulness  or  a  tympanitic  note ;  over  a  bronchiectatic  cavity 
the  note  is  amphoric.  The  note  over  the  unaffected  side  is  hyper-resonant. 
Auscultation  over  lung  that  is  solidified  by  fibrous  change  reveals  a  dimin- 
ished respiratory  murmur,  broncho-vesicular  or  even  bronchial  breathing,  or, 
if  a  cavity  is  present,  amphoric  breathing.  The  voice  corresponds  to  the 
respiratory  sounds.  The  hypertrophy  of  the  right  ventricle  of  the  heart 
results  in  an  accentuated  second  pulmonic  sound;  failure  of  this  ventricle 
is  evidenced  by  the  appearance  of  cardiac  murmurs. 

The  diagnosis  is  usually  easy;  fibroid  phthisis  may,  however,  be  mistaken 
for  interstitial  pneumonia.  Differentiation  may  be  made  upon  the  more 
frequent  fever,  signs  of  tuberculosis  in  the  other  lung  and  upon  the  presence 
of  tubercle  bacilli  in  the  sputum  in  the  former  condition. 

The  prognosis  is  unfavorable  as  to  recovery.  The  course  of  the  disease 
is  prolonged — ten  years  or  even  more.  Death  usually  takes  place  from 
gradual  failure  of  the  right  side  of  the  heart,  more  rarely  from  hyaline  degener- 
ation of  the  viscera,  or  haemoptysis. 

Treatment  consists  in  the  employment  of  tonics,  nourishing  food  and  all 
measures  calculated  to  improve  the  patient's  general  condition.  Life  in  a 
warm  dry  climate  may  do  much  to  increase  the  sufferer's  comfort  and  to  pro- 
long his  life.  Respiratory  exercises  may  be  advised  but  should  be  carried 
on  under  the  physician's  supervision.  The  cough  may  be  controlled  by  the 
means  suggested  in  the  section  on  the  treatment  of  chronic  bronchitis  and 


EMBOLIC    PNEUMONIA.  205 

should  the  sputum  become  foul  the  treatment  applicable  to  foetid  bronchitis 
is  indicated.  Hyoscyamus  or  belladonna  may  lessen  the  tendency  to  spas- 
modic cough. 

EMBOLIC  PNEUMONIA. 
Haemorrhagic  Infarct  of  the  Lung. 

.Etiology.  This  condition  is  caused  by  the  lodgment  in  one  of  the  branches 
of  the  pulmonary  artery  of  an  embolus  which  has  had  its  origin  in  or  has 
reached  the  right  heart  from  the  systemic  circulation.  Large  emboli  may 
cause  sudden  death,  smaller  ones  cause  infarcts  of  varying  size  unless  the  site 
of  lodgment  is  not  in  a  terminal  artery.  In  this  case  collateral  circulation 
may  be  established. 

Pathology.  Pulmonary  infarcts  are  conical  in  shape  and  correspond  to  that 
portion  of  the  pulmonary  area  which  is  deprived  of  its  blood  supply  by  the 
plugging  of  its  artery  by  the  embolus.  The  base  of  the  cone  is  toward  the 
periphery  of  the  lung  and  the  infarct  varies  in  size  from  that  of  a  pea  to  that 
of  an  egg;  when  fresh  it  is  red-brown  in  color  and  its  pleural  surface  projects 
beyond  the  surrounding  tissue.  The  pleura  covering  it  becomes  the  seat  of 
a  deposit  of  fibrin.  In  consistency  it  is  more  or  less  solid  owing  to  the  transu- 
dation of  blood  which  later  undergoes  an  inflammatory  change.  This  con- 
sists first  of  an  emigration  of  leucocytes  from  the  neighboring  vessels,  then 
disintegration  and  absorption  of  the  red  blood  cells  takes  place  causing  the 
dark  red  or  brownish  color  of  the  infarct  to  diminish.  Finally  the  infarct 
becomes  pale  and  the  tissues  which  have  been  the  seat  of  the  transudation 
contract  until  little  but  a  fibrous  scar  remains.  The  ultimate  result  is  a 
grayish  contracted  spot  in  the  lung.  If  there  is  a  deposit  of  haematoidin 
crystals  the  resulting  color  is  dark  red.  Larger  infarcts  may  soften  in  part 
and  disintegrate,  the  degenerated  portion  being  absorbed  or  expectorated. 
In  certain  instances  the  scar  in  the  lung  may  undergo  cheesy  degeneration 
and  calcification. 

Symptoms.  Large  emboli,  as  has  been  stated,  may  cause  sudden  death 
without  symptoms.  Smaller  emboli  are  evidenced  by  increasing  pain  in 
the  side  and,  if  a  portion  of  lung  of  considerable  size  is  obstructed,  there  is 
dyspnoea.  Cough  with  bloody  expectoration  may  be  present.  The  physical 
signs  depend  upon  the  size  of  the  infarct.  In  those  of  small  area  only  the 
signs  of  a  localized  pleurisy  are  obtainable.  If  the  consolidation  is  of  large 
extent  there  are  dulness,  exaggerated  vocal  fremitus,  crepitant  and  sub- 
crepitant  rales,  and  bronchial  voice  and  breathing. 

The  diagnosis.  The  symptoms  in  slight  instances  where  the  infarct  is  of 
small  size  may  be  insignificant.  In  more  marked  instances  the  sudden  onset 
with   pain   in   the  lung,  cough  and  dyspnoea,  without  rise  of  temperature, 


2o6  THE    INFECTIOUS    DISEASES. 

especially  if  the  patient  is  the  subject  of  arterial  disease,  renders  the  condition 
one  not  easily  to  be  mistaken. 

The  prognosis  is  good  except  when  the  embolus  is  very  large;  here  death 
may  take  place  without  warning,  a  considerable  portion  of  the  lung  being  left 
without  blood  supply. 

Treatment.  The  patient  should  be  kept  absolutely  quiet  in  bed.  The 
pain  may  be  relieved  by  counter-irritation  in  the  form  of  dry  cups  or  a  mild 
mustard  paste;  if  this  symptom  is  very  severe  morphine  may  be  necessary. 
Otherwise  the  treatment  is  wholly  symptomatic. 

Septic  Embolic  Pneumonia. 

Synonym.    Metastatic  Abscess  of  the  Lung. 

.Etiology.  This  condition  is  the  result  of  the  lodgment  of  a  septic  embolus 
in  one  of  the  vessels  of  the  lung.  Such  infective  emboli  may  become  detached 
from  a  thrombus  in  a  vessel  at  a  localized  infective  process,  such  as  a  septic 
phlebitis,  operation  wound,  compound  fracture,  septic  puerperal  uterus,  etc. 
The  embolus  passes  through  the  circulation  into  the  right  heart,  thence  it 
reaches  the  lung,  through  the  vessels  of  which  it  is  transmitted  until  it  reaches 
one  of  insufficiently  large  calibre  to  permit  its  passage;  here  it  lodges  and, 
being  loaded  with  infectious  matter,  causes  the  formation  of  an  abscess. 

Pathology.  The  early  stage  is  evidenced  by  the  appearances  found  in 
simple  pulmonary  infarct;  the  extra vasated  blood  is,  however,  more  plentiful. 
Marked  inflammation  soon  arises,  the  tissues  are  infiltrated  with  leucocytes 
which  rapidly  degenerate  into  pus  and  the  whole  area  of  the  infarct  softens 
and  becomes  an  abscess  cavity,  which  if  near  the  pleura  may  rupture  into  the 
cavity  of  this  membrane  resulting  in  pyo-pneumo-thorax,  or,  the  inflamma- 
tion spreading  by  extension,  simply  a  pyo-thorax. 

Symptoms.  The  patient  usually  is  suffering  from  pyaemia  (q.v.)  before 
the  lodgment  of  the  embolus;  this  adds  to  the  symptoms  of  the  primary 
condition  a  sudden  pulmonary  pain  and  a  chiU  followed  by  rise  of  tempera- 
ture and  diaphoresis. 

Treatment.  If  possible  the  abscess  should  be  opened  surgically  and 
drained;  otherwise  the  treatment  consists  in  the  administration  of  stimulants 
and  the  employment  of  other  means  applicable  in  pyaemic  conditions  (see 
p.  122). 

BERI-BERI. 

Synonym.     Kakkd. 

Definition.  A  multiple  neuritis  of  specific  origin  occurring  epidemically 
and  endemically  in  tropical  and  sub-tropical  countries  and  characterized  by 
motor  and  sensory  paralyses  and  a  tendency  to  oedema. 


BERI-BERI.  207 

JEtiology.  This  disease  is  most  commonly  observed  in  Malayan  countries 
where  it  attacks  chiefly  the  natives;  Europeans  are  affected  with  comparative 
infrequency.  It  prevails  extensively  in  China,  Japan  and  the  Philippines 
and  from  time  to  time  appears  in  epidemics  which  may  be  attended  by  great 
mortality.  In  our  own  country  instances  are  not  infrequently  observed  in  the 
various  seaports  and  the  disease  has  been  met  in  insane  asylums  in  Alabama 
and  Arkansas,  in  Louisiana  and  among  Chinese  fishermen  in  Alaska.  The 
chief  predisposing  cause  seems  to  be  the  aggregation  of  a  number  of  individuals 
in  crowded  quarters,  barracks,  jails,  ships,  etc.,  under  unsanitary  surround- 
ings, in  connection  with  an  improper  or  insufficient  diet.  The  disease  is  seldom 
seen  at  high  altitudes  and  warmth  and  dampness  are  the  most  favorable 
meteorological  conditions  for  its  development.  Males  are  more  frequently 
affected  because  they  are  more  frequently  exposed  and  the  majority  of  in- 
stances occur  in  adolescents  and  young  adults. 

The  theories  that  the  disease  is  caused  by  a  diet  of  fish,  of  diseased  rice, 
or  by  intestinal  parasites  are  untenable  but  it  is  a  fact  that  there  has  been 
a  great  diminution  in  beri-beri  in  the  Japanese  navy  since  a  more  general 
dietary  has  been  allowed,  which  fact  leads  Takaki  to  believe  that  a  regimen 
containing  too  much  carbohydrate  and  too  Httle  proteid  is  a  considerable 
factor  in  the  production  of  the  disease. 

The  germ  theory  of  the  affection  has  various  arguments  in  its  favor  which 
are  summed  up  by  Hamilton  Wright  in  the  statement  that  beri-beri  is  due  to  a 
specific  micro-organism  entering  by  the  mouth  and  developing  and  evolving 
a  toxin,  chiefly  at  the  pyloric  end  of  the  stomach  and  in  the  duodenum,  which 
is  absorbed  and  acts  upon  the  peripheral  endings  of  the  afferent  and  efferent 
neurons.  He  believes  that  the  specific  cause  of  the  disease  is  given  off  in  the 
faeces  and  is  capable  of  producing  the  affection  whenever  conditions  of  weather, 
climate  and  mode  of  life  are  favorable.  At  such  times  the  specific  germ  enter- 
ing the  body  upon  food  or  drink  gives  origin  to  the  disease. 

Pathology.  The  most  constant  and  characteristic  morbid  changes  are  a 
degeneration  of  the  terminal  branches  of  the  peripheral  nerves,  atrophy  of 
the  nerve  cells  of  the  heart  and  of  the  terminations  of  the  pneumogastric 
nerve;  later  the  trunk  of  this  nerve,  as  well  as  those  of  the  phrenic  and  splanch- 
nics,  is  involved.  There  is  degeneration  of  the  heart  muscle  and  of  the  volun- 
tary muscles.  Wright  has  found  in  acute  instances  congestion  and  pete- 
chial haemorrhages  in  the  pyloric  end  of  the  stomach  and  in  the  duodenum. 
He  believes  these  to  be  the  specific  pathologic  changes  of  beri-beri  and  that  they 
are  constant  in  instances  terminating  fatally  within  three  weeks  of  the  onset. 

Symptoms.  The  incubation  period  is  indefinite  but  is  probably  a  number 
of  months.  Premonitory  symptoms,  such  as  anorexia,  epigastric  pain,  respi- 
ratory oppression  and  slight  fever,  are  common;  chills  and  cerebral  symptoms 
are  more  unusual. 


2o8  THE    INFECTIOUS    DISEASES. 

Four  clinical  forms  of  the  disease  may  be  described. 

a.  The  mild  or  incomplete  form  of  whicli  the  chief  manifestations  are  pain, 
weakness  and  numbness  in  the  legs.  There  may  be  small  and  distinctly 
marked  areas  of  anaesthesia;  oedema  of  the  legs  may  be  present;  palpitation 
and  cardiac  irritability  are  common.  Muscular  weakness  and  abdominal  dis- 
tress may  occur.  Such  instances  of  the  disease  usually  last  only  a  short 
time  but  may  recur  during  the  next  warm  season  or  develop  a  sudden  acute 
attack  of  cardiac  weakness. 

b.  The  dropsical  or  wet  form  resembles  in  its  onset  the  preceding  type, 
but  oedema,  beginning  in  the  feet  and  legs  and  soon  involving  the  whole  body 
including  the  serous  cavities,  soon  appears;  the  nerve  symptoms  are  not  partic- 
ularly marked  but  cardiac  disturbance,  with  dyspnoea  and  cyanosis  is  fre- 
quent and  distressing. 

c.  The  atrophic  form  is  characterized  by  an  increasing  disability  to  walk, 
there  are  pains  and  contractions  in  the  muscles  of  the  legs;  the  paralysis 
extends  to  the  body  and  sometimes  to  the  arms;  there  are  areas  of  hyperaes- 
thesia  and  anaesthesia  and  there  may  be  extensive  atrophy  of  the  muscles  with 
wrist  and  foot  drop;  there  is  ultimate  loss  of  both  galvanic  and  faradic  irri- 
tability.    Cardiac  symptoms  are  slight  and  may  be  absent. 

d.  The  acute  pernicious  form.  Here  the  symptoms  of  onset  may  be  those 
of  the  mild  type  of  the  disease  with  suddenly  developing  manifestations  of 
cardiac  failure  or  the  attack  may  be  of  the  cardiac  type  from  its  inception. 
There  is  severe  precordial  pain  with  marked  palpitation  and  dyspnoea;  the 
patient  gasps  for  breath,  the  face  is  anxious,  the  lips  are  flecked  with 
blood-stained  froth  and  death  may  occur  within  24  hours,  but  usually  life 
is  prolonged  for  several  weeks.  Nausea  and  vomiting  and  diminished 
or  suppressed  urine  are  often  seen  when  the  disease  is  near  its  termination. 

Fever  is  not  usually  noted  after  the  onset  of  beri-beri  unless  caused  by  a 
complication  or  a  recrudescence.  Various  cutaneous  manifestations,  such  as 
mottling  of  the  limbs  and  petechial  and  herpetic  eruptions  of  the  lips,  are  not 
infrequent.  The  urinary  solids  are  usually  diminished  as  also  is  the  total 
quantity  of  this  excretion.     Albuminuria  is  not  present. 

The  diagnosis  in  the  tropics  is  easy  and  instances  of  neuritis,  especially  if 
associated  with  cedema,  seen  upon  vessels  coming  from  tropical  ports  should 
be  viewed  with  suspicion.  In  doubtful  instances  irritability  of  the  heart,  if  pres- 
ent, is  strongly  in  favor  of  beri-beri. 

The  prognosis  in  the  pernicious  instances  is  most  unfavorable;  in  other  types 
the  mortality  varies  in  different  epidemics  from  2  or  3  to  40  percent.  It 
must  be  remembered  that  patients  apparently  doing  well  may  suddenly  mani- 
fest most  distressing  heart  symptoms.  The  sensory,  motor  and  trophic  dis- 
turbances are  not  permanent. 

Treatment.     Much  may  be  done  in  the  way  of  prevention.     The  diet 


MYCETOMA , 


209 


should  be  rich  in  fatty  and  nitrogenous  food  and  if  rice  enters  into  the 
regimen  it  is  preferably  eaten  unhusked.  All  over-crowding  should  be 
avoided. 

The  diet  of  a  sufferer  from  the  disease  should  be  generous  and  regulated 
in  accordance  with  the  suggestions  given  above.  If  possible  he  should  move 
to  another  climate,  failing  this  he  should  be  allowed  to  be  up  and  in  the  open 
air  as  much  as  possible  and  his  apartment  should  be  one  which  may  be  thor- 
oughly ventilated  and  to  which  the  sun  has  free  access.  Massage  and  frictions 
should  be  prescribed  and  in  the  dropsical  type  of  the  disease  this  symptom 
may  be  relieved  in  the  usual  manner  by  means  of  diuretics  and  diaphoretics; 
the  bowels  sliould  be  opened  by  laxatives  when  necessary.  Accumulations 
of  fluid  in  the  serous  sacs  may  be  drawn  off  by  aspiration  if  indication  exists. 
In  the  atrophic  type  faradism,  galvanism,  massage,  hot  and  cold  douches 
and  frictions  are  useful.  The  cardiac  attacks  necessitate  the  administration 
of  stimulants  and  here  our  chief  dependence  should  be  placed  upon  inhala- 
tions of  amyl  nitrite  in  emergencies  and,  if  necessary,  upon  the  continued  use 
of  erythrol  tetranitrate.  The  action  of  this  drug  is  quicker  than  that  of 
glyceryl  nitrate  (nitroglycerine),  to  which  it  is  analogous,  and  tolerance  is 
not  easily  established;  it  is  best  given  in  pills  of  ^  a  grain  (0.032),  made  up 
with  kaolin,  every  4  to  6  hours.  Glyceryl  nitrate  is  also  useful  as  is  digitalis 
in  full  doses.  Venesection  and  the  withdrawal  of  12  to  14  ounces  (350.0  to 
420.0)  of  blood  will  often  tide  the  patient  through  a  cardiac  paroxysm.  The 
precordial  pain  and  sense  of  oppression  may  be  relieved  by  the  hypodermatic 
use  of  morphine. 

Tonics  have  a  place  in  combating  the  tendency  to  wasting  and  anaemia, 
and  arsenic,  potassium  iodide,  iron,  the  glycerophosphates  and  strychnine 
are  all  useful.  The  hypodermatic  injection  of  the  following  prescription  has 
been  suggested.  Sodium  cacodylate  i^  parts,  iron  and  ammonium  citrate 
3  parts,  strychnine  sulphate  yfo  part  and  water  25  parts.  The  dose  is 
7^  minims  (0.5)  at  first,  to  be  gradually  increased  to  double  this  amount. 

The  treatment  of  the  paralyses  and  of  the  muscular  atrophy  is  identical 
with  that  of  similar  conditions  occurring  in  an  ordinary  multiple  neuritis. 
(See  p.  789.) 

MYCETOMA. 

Synonyms.     Madura  Foot;  Fungus  Foot. 

Definition.  A  disease  of  one  or  both  feet  due  to  mycotic  infection  and 
characterized  by  the  appearance  of  black  granules  (the  melanoid  type)  or 
yellow  or  white  granules  (the  ochroid  type). 

.Etiology.  The  disease  is  caused  by  one  of  two  varieties  of  streptothrix, 
the  melanoid  form  by  strepothrix  madio-cr,  the  ochroid  form  by  streptothrix 
14 


2IO  THE    INFECTIOUS    DISEASES. 

mycetoma.  The  organisms  are  nearly  akin  to  the  ray  fungus.  Madura 
foot  is  most  common  in  India  but  is  observed  in  other  Asiatic  countries, 
Europe  and  South  America. 

Symptoms.  The  nodules  appear  upon  the  sole  and  are  at  first  hard  and 
dense,  later  they  break  down  and  persistent  sinuses  result  which  discharge 
a  foul  pus  which  contains  the  black  or  yellow  granules.  The  foot  increases 
in  size  and  ultimately  all  its  tissues  become  involved,  a  soft  oily  mass  resulting. 
The  appearance  of  the  affected  extremity  is  typical,  its  surface  being  the  seat 
of  the  discharging  sinuses,  its  sole  thickened  and  the  toes  extended.  The  ray 
fungus  may  cause  a  similar  condition  which  may  be  differentiated  from  true 
madura  foot  by  microscopic  examination  of  the  organisms  contained  in  the 
discharge.  In  certain  instances  there  may  be  metastases  in  other  parts,  the 
disease  being  transmitted  by  the  lymphatics. 

Treatmient  is  wholly  surgical.  Excision  of  the  diseased  tissues  may  be 
effectual  if  done  early  enough;  when  the  entire  extremity  is  involved  amputa- 
tion becomes  necessary. 

FEBRICULA. 

Synonyms.     Ephemeral  Fever;  Irritative  Fever. 

Definition.  A  transient  febrile  disease  due  to  any  one  of  a  number  of 
irritant  causes.  The  term  ephemeral  fever  is  applied  to  instances  in  which 
the  rise  of  temperature  lasts  not  over  24  hours.  If  the  febrile  movement 
persists  for  several  days  the  condition  may  be  denominated  febricula. 

jEtiology.  The  usual  cause  of  these  disturbances  is  a  disorder  of  the 
digestive  function,  caused  either  by  temporary  derangement  or  by  some  irri- 
tant or  toxic  quality  of  the  ingested  food,  by  the  changes  in  which  ptomaines 
or  toxalbumins  g,re  produced — intestinal  auto-intoxication.  The  existence 
in  the  body  of  the  specific  setiologic  factor  of  one  of  the  infectious  diseases 
in  insufficient  amount  to  cause  the  typical  manifestation  of  the  affection  may 
result  in  an  abortive  form  of  the  infection  which  may  disappear  within  a  few 
davs  without  having  been  evidenced  by  any  characteristic  symptom.  Such 
conditions  may  be  met  in  epidemics  of  scarlatina,  enteric  fever,  etc.,  and  other 
instances  of  idiopathic  fever  may  be  attributed  to  abortive  types  of  pneumonia, 
rheumatism,  tonsilhtis,  etc.  The  inhalation  of  sewer  gas  and  of  other  foul 
odors  has  been  held  responsible  for  the  occurrence  of  transitory  fevers  but 
it  is  possible  that  the  condition  has  been  mistakenly  attributed  to  these 
causes. 

Symptoms.  These  are  usually  sudden  in  onset  but  may  be  preceded  by 
indefinite  malaise.  Rarely  is  there  an  initial  chill.  The  rise  in  temperature 
is  seldom  over  103°  F.  (39.5°  C),  the  pulse  is  rapid,  there  are  headache,  bodily 
weakness,  a  coated  tongue,  loss  of  appetite,  nausea  and  vomiting.     There 


PROTRACTED    IDIOPATHIC    CONTINUED    FEVER.  211 

may  be  either  constipation  or  diarrhoea;  the  urine  is  dark,  scanty,  and  often 
loaded  with  urates.  Nervous  symptoms,  even  deUrium,  are  often  observed 
in  children.  The  temperature  usually  falls  by  crisis  within  a  few  days  or  a. 
week. 

The  diagnosis  must  be  made  by  exclusion.  The  absence  of  cutaneous 
manifestations  or  of  local  symptoms  and  the  disappearance  of  the  febrile 
movement  within  a  few  days  are  the  most  important  points. 

Treatment  consists  in  clearing  the  alimentary  tract  by  the  administration  of 
repeated  small  doses  of  calomel — J  of  a  grain  (0.016)  every  ^  hour  to  6  doses — 
followed  by  a  saUne  purge,  the  restriction  of  the  diet  to  fluids,  the  induction 
of  free  action  of  the  skin  and  kidneys  by  giving  the  sweet  spirit  of  nitre  and 
one  of  diuretic  potassium  salts.  The  patient  should  remain  in  bed  during 
the  febrile  movement  and  tincture  of  aconite,  2  to  3  minims  (0.13  to  0.2)  given 
every  2  or  3  hours  will  tend  to  control  this  symptom  and  lessen  the  cardiac 
rapidity.  Should  there  be  marked  evidence  of  intestinal  putrefaction  this 
may  be  combated  by  means  of  one  of  the  bismuth  salts,  preferably  the  tetra- 
iodophenolphthaleinate. 

PROTRACTED  IDIOPATHIC  CONTINUED  FEVER. 

From  time  to  time  fevers  are  observed  which  last  from  a  few  weeks  to 
several  months  and  present  no  symptoms  which  aid  in  ascertaining  their 
specific  cause.  These  may  be  atypical  forms  of  the  various  infectious  diseases, 
enteric  fever,  malta  fever,  etc.,  they  may  be  due  to  pyogenic,  or  rarely  to 
pneumococcic  infection.  Their  chief  symptoms  are  a  moderate  febrile 
movement  lower  in  the  morning,  higher  in  the  evening,  prostration,  impair- 
ment of  digestive  function,  prostration  and,  it  may  be,  manifestations  referable 
to  the  nervous  system.  The  spleen  may  be  enlarged.  These  fevers  are  to 
be  distinguished  from  enteric  fever  by  the  absence  of  the  Widal  reaction, 
from  malaria  by  their  resistance  to  quinine  and  the  absence  of  the  Plasmo- 
dium, from  tuberculosis  by  the  absence  of  tubercle  bacilli  in  the  excretions 
and  failure  to  respond  to  the  tuberculin  test.  In  the  instances  due  to  pyo- 
genic infection  the  presence  of  an  increased  leucocytosis  should  aid  in  ascer- 
taining the  cause. 

These  patients  usually  recover,  fatal  instances  developing  in  most  subjects 
manifestations  from  which  an  absolute  diagnosis  of  some  infection  can  be 
made. 

Treatment  is  eliminative  and  symptomatic ;  the  bowels,  skin  and  kidneys 
should  be  kept  active,  the  diet  should  be  of  nourishing  and  easily  digestible 
fluids  and  the  various  symptoms  should  be  relieved  as  they  appear.  The 
patient's  strength  should  be  further  maintained  by  the  administration  of 
tonics,  particularly  iron,  quinine  and  strychnine,  in  small"  doses. 


212  THE    INFECTIOUS    DISEASES. 

WEIL'S  DISEASE. 

Synonyms.  Acute  Febrile  Jaundice;  Infectious  Jaundice;  Epidemic  Catar- 
rhal Jaundice. 

Definition.  An  acute  disease,  probably  due  to  a  specific  infection  and 
characterized  by  a  remittent  febrile  movement,  jaundice  and  pains  in  the 
muscles. 

Etiology.  This  affection  usually  attacks  individuals  in  young  or  middle 
life  and  males  rather  than  females.  It  is  more  common  in  the  summer  months 
and  epidemics  have  been  described  as  occurring  in  various  parts  of  the  vs^orld 
as  India,  Egypt  and  South  Africa.  It  is  rare  in  Europe  and  America  although 
it  has  appeared  in  Greece  and  in  North  Carolina.  Butchers  seem  particularly 
prone  to  the  infection  and  it  is  also  frequent  in  brewers  and  laboring  men. 

The  specific  cause  is  not  known  but,  while  the  bacillus  proteus  fliwrescens 
has  been  held  responsible  by  certain  observers,  it  is  probable  that  the  condi- 
tion may  be  caused  by  a  number  of  infectious  agents. 

Pathology.  Post  mortem  examination  reveals  nothing  characteristic, 
The  intestinal  mucosa  may  be  congested  and  the  liver  and  spleen  hyperaemic ; 
there  may  be  acute  degeneration  (cloudy  swelling)  of  the  kidneys. 

Symptoms.  The  onset  of  the  disease  is  usually  sudden,  with  a  chill,  fol- 
lowed by  fever,  headache,  nausea  and  perhaps  vomiting  and  general  pains; 
the  temperature  is  remittent  and  seldom  rises  above  104°  F.  (40°  C). 
Jaundice  is  an  early  symptom  and  is  very  variable  in  intensity;  the 
stools  may  be  clay  colored.  The  liver  and  spleen  may  be  enlarged 
and  the  former  is  often  tender.  The  urine  is  dark,  heavy,  and  contains 
albumin  and  casts,  bile  pigments  and  perhaps  blood.  In  the  severer  infections 
nervous  symptoms  and  even  delirium  may  be  present.  The  fever  lasts  from 
8  days  to  2  weeks  and  falls  by  lysis  as  a  rule.     Secondary  fever  may  occur. 

The  diagnosis  from  bilious  malarial  fever  may  be  made  by  the  failure  to 
find  Plasmodia  in  the  blood;  from  acute  catarrhal  jaundice  by  the  presence 
of  fever  and  pains;  from  acute  yellow  atrophy  of  the  liver  and  phosphorus 
poisoning  by  the  favorable  course  and  outcome. 

The  prognosis  as  to  recovery  is  good  as  a  rule  but  certain  epidemics  have 
been  characterized  by  a  considerable  mortality. 

Treatment  is  eliminative,  supportive  and  symptomatic.  For  the  first  con- 
sideration small  doses  of  calomel  to  free  purgation  followed  by  sodium  phos- 
phate once  daily  until  convalescence  is  established,  should  be  prescribed. 

GLANDULAR  FEVER. 

Definition.  An  acute  infectious  disease  of  mild  type,  occurring  chiefly 
in    children   and   characterized   by    moderate   pharyngeal   congestion,   fever 


MILIARY    FEVER.  213 

and  enlargement  of  the  cervical  lymphatic  glands,  and,  at  times,  those  of  the 
axillae  and  inguinal  region  as  well. 

etiology.  This  affection  is  seldom  seen  after  the  age  of  16  years  and 
most  instances  are  observed  during  the  colder  months.  While  probably  due 
to  a  micro-organism  which  effects  entry  through  the  tonsils  or  pharynx,  no 
specific  cause  for  the  disease  has  been  isolated.  Epidemics  of  glandular 
fever  occur  from  time  to  time  and  the  condition  seems  to  be  contagious  since 
if  often  affects  several  children  of  the  same  family. 

Pathology.  The  lymph  glands  are  enlarged  but  if  they  suppurate  this  is 
probably  the  result  of  some  secondary  infection;  there  is  said  to  be  enlarge- 
ment of  the  liver  and  spleen.  Certain  observers  state  that  there  is  accom- 
panying enlargement  of  the  lymph  nodes  of  the  bronchi  and  mesentery  but 
others  refute  this  assertion. 

Symptoms.  After  an  incubation  of  from  5  to  8  days  the  disease  is  suddenly 
ushered  in  with  stiffness  in  the  neck,  pain  upon  moving  the  head,  loss  of 
appetite,  nausea  and  sometimes  vomiting.  There  are  pains  in  the  head, 
abdomen  and  limbs.  The  temperature  rises  to  102°  to  104°  F.  (38°  to  40°  C), 
the  tongue  is  coated  and  the  cheeks  are  flushed.  After  24  to  48  hours,  palpa- 
tion in  the  cervical  region  reveals  enlargement  and  tenderness  of  the  lymph 
glands.  The  throat  and  tonsils  may  be  congested.  The  axillary  and  in- 
guinal glands  may  be  swollen.  The  evening  temperature  persists  for  from 
2  days  to  a  week  when  it  falls  to  normal  either  gradually  or  by  crisis;  the  symp- 
toms soon  ameliorate,  but  while  the  tenderness  of  the  lymph  glands  disappears 
their  enlargement  may  persist  for  several  weeks.  Recovery  takes  place 
almost  without  exception. 

The  diagnosis  is  simple,  the  various  types  of  angina  which  are  accompanied 
by  glandular  involvement  being  excluded  by  examination  of  the  pharynx. 

Treatment.  At  the  onset  the  bowels  should  be  freely  moved,  preferably 
by  divided  small  doses  of  calomel.  The  fever  and  restlessness  may  be  con- 
trolled by  sponging  with  cool  water  or  by  small  doses  of  acetphenetidine 
(phenacetine)  or  antipyrine.  Rest  in  bed  and  a  fluid  diet  should  be  en- 
joined during  the  febrile  period.  Cold  or  warm  compresses  may  be  applied 
to  the  tender  glands;  a  compress  wet  in  cold  mercury  bichloride  solution  has 
been  recommended.  The  after  treatment  consists  in  the  administration 
of  tonics,  especially  the  syrup  of  iron  iodide  and  codliver  oil. 

MILIARY  FEVER. 

Synonym.     Sweating  Sickness. 

Definition.  An  infectious  disease  characterized  by  fever,  profuse  sweat- 
ing and  an  eruption  of  miliary  vesicles. 

Etiology.  Very  little  is  known  of  the  causation  of  this  affection;  it  occurs 
in  epidemics  which  are  distinctly  localized;  often  the  inhabitants  of  a  certain 


214  THE    INFECTIOUS    DISEASES. 

town  or  district  only  are  afflicted.  It  occurs  most  often  in  the  spring  and 
summer  months  and  seems  to  attack  women  more  frequently  than  men. 
It  is  a  disease  of  adults.  Unhealthy  surroundings  and  lack  of  sanitation 
do  not  seem  to  be  predisposing  causes.  At  present  the  disease  is  seldom 
seen  outside  of  France  and  Italy. 

Pathology.  No  characteristic  morbid  changes  have  been  described.  The 
spleen  may  be  enlarged;  the  blood  is  thin  and  dark. 

Symptoms.  Mild  prodromata  such  as  malaise,  headache  and  anorexia 
may  precede  the  invasion  of  the  disease  or  the  onset  may  take  place  abruptly, 
the  patient,  after  retiring  in  apparently  good  health,  waking  in  the  night 
bathed  in  profuse  perspiration.  The  sweating  persists  and  the  patient 
suffers  from  precordial  oppression  or  pain,  epigastric  discomfort,  headache, 
muscular  cramps,  prostration  and  the  other  usual  symptoms  of  febrile 
disease.  The  temperature  is  elevated,  the  pulse  accelerated,  the  respiration 
rapid.  On  the  3d  or  4th  day  there  is  a  tingling  of  the  skin  followed 
by  an  eruption  of  tiny  miliary  vesicles  containing  clear  fluid  which  later 
may  become  turbid.  The  vesicles  rapidly  increase  in  size  and  appear  first 
upon  the  neck  and  chest,  spreading  thence  to  the  back  and  limbs.  They 
break  after  2  to  4  days  and  crusts  form  which  later  fall.  With  the  incidence 
of  the  eruption  the  other  symptoms  abate.     Rapid  emaciation  is  characteristic. 

The  disease  usually  lasts  about  a  week  but  is  sometimes  more  protracted, 
the  rash,  at  times,  being  delayed  even  for  2  weeks.  Severe  instances  with 
haemorrhages  or  pronounced  cerebral  symptoms  have  been  observed.  Relapses 
are  not  infrequent. 

The  diagnosis  during  an  epidemic  is  easy.  The  profuse  diaphoresis  and 
the  miliary  eruption  are  characteristic. 

The  prognosis  varies,  the  mortality  in  certain  epidemics  being  high;  the 
mean  death-rate  is  stated  to  be  from  8  to  9  percent. 

Treatment.  The  channels  of  elimination  should  be  kept  freely  open  by 
means  of  laxatives  and  diuretic  drinks.  Quinine  is  said  to  be  efficient  in 
controlling  the  fever.  The  excessive  sweating  may  be  relieved,  if  necessary, 
by  means  of  repeated  hypodermatic  injections  of  yin  of  a  grain  (0.0006) 
of  atropine  sulphate  and  the  patient's  comfort  may  be  greatly  augmented 
by  frequent  sponging  with  tepid  water.  The  sense  of  cardiac  and  respiratory 
oppression,  if  distressing,  may  necessitate  the  employment  of  hypodermatic 
injections  of  morphine.  The  patient  should  be  kept  in  bed  during  the  acuity 
of  the  attack  and  the  diet  should  consist  of  nourishing  and  easily  digestible 
liquids. 

JAPANESE  RIVER  FEVER. 

Definition.  Japanese  river,  or  flood  fever,  is  an  acute  infectious  febrile 
disease  which  is  observed  in  the  workers  who  till  the  submerged  banks  of 


TICK    FEVER.  21 5 

certain  Japanese  rivers.  Its  causation  is  not  definitely  known  but  it  seems 
to  be  borne  by  corn  or  hemp  and  at  the  point  of  its  entrance  into  the  body  an 
ulcer  is  developed.  The  natives  believe  the  disease  to  be  the  result  of  the 
bite  of  an  insect. 

Autopsy  reveals  no  characteristic  morbid  changes;  bronchial  congestion, 
considerable  enlargement  of  the  spleen  and  of  the  mesenteric  lymph  nodes 
may  be  found. 

Symptoms.  The  invasion  of  the  disease  is  marked  by  the  appearance  of 
a  round  ulcer  in  the  inguinal  region,  neck  or  axilla.  This  may  be  preceded 
by  a  prodromal  period  of  several  days  during  which  the  patient  complains 
of  weakness  and  chills.  Following  the  initial  lesion  there  are  lymphangitis 
of  the  vessels  draining  the  region  of  the  eschar,  conjunctivitis,  bronchitis  and 
a  moderately  high  temperature.  At  the  end  of  6  days  or  a  week  a  rash,  con- 
sisting of  red  papules,  breaks  out  upon  the  face,  limbs  and  body;  this  persists 
for  from  a  day  or  two  to  a  week.  The  elevation  of  temperature  continues  for 
about  7  days  more  when  the  initial  ulcer  begins  to  heal,  the  symptoms  abate 
and  rapid  defervescence  takes  place. 

The  prognosis  varies;  in  certain  epidemics  the  disease  is  very  fatal. 

Treatment  consists  in  rendering  the  primary  sore  surgically  clean  and 
maintaining  it  in  this  condition,  the  appHcation  of  cold  to  the  lymphangitis 
and  the  employment  of  approved  methods  to  relieve  the  other  symptoms 
as  they  arise.  The  cautious  use  of  quinine  and  sodium  salicylate  has  been 
advised. 

TICK  FEVER. 

Definition.  This  is  a  disease  prevalent  in  certain  parts  of  Africa,  partic- 
ularly in  the  Congo,  in  western  Uganda  and  in  the  western  portions  of  Ger- 
man East  Africa. 

The  affection  is  due  to  the  introduction  into  the  body,  by  means  of  the  bite 
of  a  certain  variety  of  tick,  the  ornithodoriis  moubata,  of  a  spirillum. 

Observations  upon  this  disease  seem  to  show  that  the  period  intervening 
between  the  bite  and  the  declaration  of  the  disease  is  about  one  week.  The 
invasion  is  abrupt  but  not  marked  by  a  distinct  chill.  There  is  prostration 
and  the  patient  complains  of  headache  and  pain  in  the  back  and  limbs. 
Food  is  distasteful  and  vomiting  at  the  invasion  is  usual;  moderate  diarrhoea 
is  common.  The  temperature  is  highest  in  the  evening,  an  elevation  of 
104.5°  F.  (40.3°  C.)  not  being  uncommon.  There  are  usually  3  to  4  attacks 
of  fever  which  often  terminate  in  sweating.  Each  attack  lasts  3  or  4  days 
and  the  intervals  from  5  to  19  days.  Splenic  enlargement  may  be  observed 
and  herpes,  hiccough  and  epistaxis  may  occur.  The  principal  character- 
istic of  the  affection  seems  to  the  prostration  during  the  febrile  attack  and 
the  quick  return  to  comparative  health  with  the  subsidence  of  the   tern- 


2l6  THE    INFECTIOUS    DISEASES. 

perature.  Under  proper  care  the  disease  is  seldom  fatal  and  it  would  seem 
that  one  attack  confers  immunity. 

The  ticks  which  inoculate  this  disease  into  the  human  being  infest  the  rest 
houses  along  the  traveled  roads  and  seem  to  be  nocturnal  in  their  habits. 

The  natives,  when  bitten,  burn  the  ticks  which  they  are  able  to  capture 
and  rub  the  ashes  into  the  scarified  skin  at  the  site  of  the  bite  as  a  preventive 
of  the  fever. 

TRYPANOSOMIASIS. 

Definition.  This  term  is  applied  to  the  two  conditions  which  may  result 
from  the  occurrence  within  the  human  body  of  the  trypanosoma  gambiense. 
This  trypanosome  is  an  elongated  flagellated  body  in  length  2  to  4  times  the 
diameter  of  a  red  blood  cell;  its  body  is  fusiform,  more  or  less  curved  and 
spirally  twisted,  and  is  elongated  into  a  single  flagellum  at  one  end;  an  undu- 
latory  membrane  extends  throughout  its  length,  at  the  base  of  which  at  the 
non-flagellate  end  is  a  small  refractive  body  which  is  regarded  as  a  centrosome. 
Near  the  middle  of  the  body  is  an  oval  nucleus.  It  is  analogous  to  several 
other  trypanosomes,  notably,  /.  Brncei  and  /.  Evansi  which  are  respectively 
parasites  of  horses  and  cattle  and  rats,  and  is  transmitted  to  man  by  the  bite 
of  the  human  tsetse  fly  {glossina  papalis),  and  perhaps  by  other  means. 

The  conditions  which  result  from  inoculation  with  the  trypanosoma  gam- 
biense are  the  so-called  trypanosoma  fever  and  sleeping-sickness  or  African 
lethargy.  Both  these  affections  occur  at  present  only  in  the  tropical  regions 
although  instances  have  been  imported  into  other  countries  in  the  past.  The 
blacks  are  chiefly  affected,  trypanosomiasis  being  extremely  rare  in  the 
white  colonists  and  missionaries;  one  or  two  cases  of  sleeping-sickness  in 
Caucasians,  have,  however,  been  reported. 

It  is  a  recognized  fact  that  the  trypanosomes  may  be  present  in  the  blood 
without  causing  significant  symptoms  but  under  certain  conditions  definite 
manifestations  occur. 

Trypanosoma  fever  is  characterized  by  a  temperature  of  irregular  type 
which  may  reach  104°  F.  (40°  C.)  and  may  be  continuous  or  remittent.  At 
intervals  of  from  a  few  days  to  2  or  3  weeks,  periods,  during  which  the  tem- 
perature falls  to  normal,  occur.  Erythematous  patches  and  scattered  areas 
of  oedema,  the  latter  being  particularly  likely  to  involve  the  lower  eyelids, 
may  appear.  The  pulse-rate  is  rapid,  the  tongue  is  red,  and  there  is  pro- 
gressive wasting  and  weakness.  The  superficial  lymph  glands  are  enlarged 
and  examination  of  their  fluid  contents  frequently  reveals  the  presence  of  the 
trypanosome.  Blood  examination  shows  a  moderate  ancemia  and  an  in- 
crease in  the  number  of  large  mononuclear  leucocytes  as  well  as  the  pres- 
ence of  the  trypanosome;  the  last  may  be  absent  at  times  for  considerable 
periods. 


KALA-AZAR.  21 7 

Treatment.  The  patient  should  be  kept  in  bed  and  so  protected  that  he 
cannot  be  bitten  by  the  flies  which  transmit  the  disease,  in  order  that  he  may  not 
prove  a  source  of  further  infection.  The  diet  should  be  nutritious  and  easily 
digestible.  Arsenic  seems  to  have  some  effect  upon  the  parasites  in  the  blood 
and  may  be  administered  hypodermatically.  The  best  resiilts  are  said  to 
be  obtained  by  iron  arsenate  and  sodium  cacodylate.  Ehrlich  and  Shiga 
consider  that  a  new  aniline  dye,  trypan-red,  is  useful  in  this  affection.  It  is 
said  to  have  no  direct  effect  upon  the  parasites  within  the  body  but  is  believed 
to  possess  the  property  of  causing  a  reaction  which  results  in  their  destruction. 
Malachite  green  may  also  be  employed.  The  combination  of  these  substances 
with  arsenic  has  been  suggested.  Otherwise  the  treatment  is  wholly  symp- 
tomatic. 

Sleeping-sickness  is  a  clironic  condition  resulting  from  the  presence  of  the 
trypanosoma  gambiense  in  the  cerebrospinal  fluid  and  is  probably  the  termi- 
nal stage  of  trypanosoma  fever.  It  occurs  chiefly  in  negroes,  less  frequently 
is  it  seen  in  half-breeds. 

Pathology.  The  disease  is  a  meningo-encephahtis.  After  death  the 
cerebrospinal  fluid  is  found  to  contain  red  blood  ceUs,  leucocytes  and  try- 
panosomes.  The  capillaries  of  the  brain  and  cord  are  surrounded  by  an 
infiltration  of  round  cells.  A  mixed  infection  with  streptococci  may  be 
observed  late  in  the  disease. 

Symptoms.  After  a  prolonged  incubation  period,  perhaps  of  several 
years,  the  invasion  takes  place  and  may  be  characterized  by  various  symptoms 
referable  to  the  nervous  system,  such  as  convulsions  and  mental  disturbances; 
there  may  be  headache,  dizziness  and  elevation  of  temperature.  When  the 
affection  has  fully  developed  the  patient  suffers  from  mental  dulness  and 
lethargy,  from  which  he  may  be  aroused  to  perform  the  bodily  functions; 
speech  is  indistinct,  the  gait  is  uncertain  and  immediately  upon  being  left 
to  himself  the  patient  falls  into  deep  slumber  from  which  it  becomes  pro- 
gressively harder  to  arouse  him.  The  body  gradually  wastes,  bed  sores  make 
their  appearance  and  death  takes  place  either  from  secondary  infection  or  in 
coma  preceded  by  paralysis  or  convulsions. 

Fluid  drawn  by  lumbar  puncture  contains  the  trypanosome.  The  disease 
may  last  for  several  years  and  it  is  believed  to  be  uniformly  fatal  in  outcome. 

Treatment  is  probably  ineffectual  but  free  purgation  early  in  the  infection 
and  the  administration  of  arsenic  in  large  doses  and  of  the  other  substances 
mentioned  under  the  treatment  of  trypanosoma  fever  is  advised. 

KALA-AZAR. 

Synonyms.     Tropical  Splenomegaly;  Dum-dum  Fever. 

Definition.     A  distinct  chronic  infectious  disease  of  tropical  regions  char- 


2l8  THE    INFECTIOUS    DISEASES. 

acterized  by  persistent  remittent  fever,  anaemia,  emaciation,  cutaneous  pig- 
mentation and  hepatic  and  splenic  enlargement. 

Etiology.  The  results  of  recent  research  lead  us  to  believe  that  kala-azar 
is  a  disease  distinct  from  every  other  and  not,  as  has  hitherto  been  supposed 
by  certain  observers,  in  any  vi^ay  connected  w^ith  malaria.  Its  specific  cause 
is  probably  the  so-called  Leishman-Donovan  parasite.  This  organism  is 
a  form  of  trj^anosome  and  is  probably  to  be  found  in  the  blood,  particularly 
that  withdrawn  by  splenic  puncture,  at  some  period  in  every  instance  of  the 
disease.  It  is  a  fusiform,  circular  or  ovoid  body  with  a  spherical  nucleus 
at  one  side;  a  number  of  these  may  be  grouped  in  the  form  of  a  rosette. 

Kala-azar  occurs  in  low-lying,  more  or  less  water-logged  districts  of  Asia 
and  Egypt  where  the  rainfall  is  heavy.  Natives  are  most  frequently  at- 
tacked, the  disease  being  rare  in  Europeans. 

Symptoms.  The  onset  of  the  affection  is  marked  by  chills,  fever  and 
gastric  irritability.  Splenic  enlargement  is  constant,  increase  in  the  size  of 
the  liver  is  frequent.  The  temperature  is  of  irregularly  remittent  type  and 
may  persist  for  months;  periods  when  the  fever  is  absent  may  occur  from 
time  to  time.  The  patient  becomes  emaciated  and  anaemic,  haemorrhages 
into  the  skin  and  mucous  membranes  may  take  place  and  purpuric  rashes 
and  evanescent  oedema  may  be  observed.  A  grayish  or  blackish  pigment 
may  be  deposited  in  the  skin  and  there  are  muscular  pains.  The  death  rate 
is  high,  complications,  particularly  dysentery,  being  often  responsible. 

Treatment.  Isolation  and  quarantine  should  be  insisted  upon  for  it  has 
been  shown  that  by  these  means  the  disease  can  be  made  to  disappear.  Qui- 
nine has  no  specific  action  upon  the  cause  of  the  infection  but  may  control 
the  temperature  to  some  extent.  The  treatment  consists  chiefly  in  the  employ- 
ment of  hygienic  and  symptomatic  measures  and  in  combating  the  anaemia 
and  bodily  wasting  by  nourishing  food  and  tonics.  The  removal  of  the 
patient  from  the  infected  district  is  advisable. 

KUBISAGARI. 

Definition.  This  is  an  endemic  disease  of  northern  Japan  similar  to  the 
endemic  paralytic  vertigo  of  Switzerland,  or  Gerlier's  disease.  Its  causation 
is  unknown  but  it  seems  to  occur  in  individuals  who  live  in  close  association 
with  their  cattle.  Males  and  females  of  all  ages  are  attacked  and  the  affec- 
tion is  most  common  diiring  the  warm  season. 

Symptoms.  The  course  is  protracted  and  is  characterized  by  ptosis,  double 
vision  and  impairment  of  sight  and  of  the  power  of  certain  groups  of  muscles, 
especially  those  of  the  back  of  the  neck,  resulting  in  a  falling  forward  of  the 
head.  Paralysis,  partial  or  entire,  of  the  masticatory,  pharyngeal  or  leg 
muscles  results,  with  interference  with  the  performance  of  their  functions. 


LEPROSY.  219 

In  the  intervals  of  the  paroxysms  the  only  persistent  symptoms  are  the  ptosis 
and  falling  forward  of  the  head.     The  disease  is  never  fatal. 

Treatment.  The  frequency  of  the  paroxysms  may  be  somewhat  diminished 
by  the  administration  of  the  bromides,  especially  potassium  bromide,  and  the 
continued  exhibition  of  potassium  iodide  and  arsenic  is  said  to  be  of  benefit. 

LEPROSY. 

Synonym.     Elephantiasis  Graecorum. 

Definition.  A  chronic  infectious  disease  occurring  in  two  forms,  (a) 
tubercular  leprosy,  which  is  characterized  by  the  development  of  nodules  in 
the  skin  and  mucous  membranes ;  and  (b)  ancesthetic  leprosy  in  which  there  is 
a  nodular  infiltration  of  the  nerve  trunks.  The  two  forms  tend  eventually 
to  become  combined. 

.etiology.  Leprosy  has  been  known  since  the  time  of  Moses.  At  present 
it  is  endemic  in  certain  parts  of  Asia,  the  Sandwich  Islands,  the  West  Indies, 
Greece  and  Turkey,  and  instances  are  not  infrequently  seen  in  Sweden, 
Norway,  Iceland,  Australia,  South  Africa,  Mexico,  Canada,  and  in  the 
Southern  and  Northwestern  United  States. 

The  disease  attacks  both  sexes  and  all  ages  and  Hutchinson  beheves  that 
a  diet  of  fish  is  a  factor  in  its  causation,  either  inducing  a  susceptibility  by 
lessening  the  bodily  resistance  or  by  carrying  the  contagium  in  its  substance. 
A  diet  lacking  in  proteids  seems  to  predispose  to  the  disease. 

The  specific  cause  is  the  bacillus  leprce  a  micro-organism  closely  resembling 
the  tubercle  bacillus  in  certain  particulars  but  easily  differentiated  by  staining. 

Mode  of  transmission.  It  is  probable  that  very  close  association  with 
patients  is  necessary  to  acquirement  of  the  disease,  for  physicians  and  nurses 
who  are  in  close  contact  with  sufferers  are  seldom  attacked.  The  possibility 
of  the  hereditary  transmission  of  the  affection  is  to  be  considered  but  it  is 
without  doubt  of  the  very  rarest  occurrence.  It  is  not  certain  that  the  disease 
may  be  contracted  by  direct  inoculation  but  it  is  probable  that  this  is  the  case. 

The  bacilli  are  given  off  in  the  discharges  of  suppurating  lesions,  in  the 
saliva  and  nasal  mucus  when  there  are  leprous  manifestations  in  the  throat 
or  nose,  and  have  been  found  in  the  urine  and  milk.  They  may  be  borne 
upon  clothing  and  the  disease  has  been  transmitted  by  fomites.  The  most 
probable  portal  of  entry  for  the  contagium  is  through  the  respiratory  tract, 
and  certain  observers  believe  that  it  may  be  contracted  during  coitus  in  the 
same  fashion  as  syphilis. 

Pathology.  The  nodes  occurring  on  the  mucous  membrane  and  skin  in 
the  tubercular  form  of  the  disease  are  composed  of  small  cells  supported 
upon  a  framework  of  connective  tissue;  within  and  between  these  cells  the 
lepra  bacilli  exist  in  large  number.  The  nodules  finally  break  down  and 
form  ulcers  which  may  heal  and  cicatrize;  in  the  ulcerative  process  fingers 


2  20  THE    INFECTIOUS    DISEASES. 

and  toes  may  be  lost  and  the  conjunctival  and  laryngeal  mucous  membranes 
may  be  affected. 

In  the  anaesthetic  type  there  is  a  peripheral  neuritis  resulting  from  the 
growth  of  the  bacilli  within  the  substance  of  the  nerve  fibres. 

Symptoms,  a.  Tubercular  leprosy:  An  intermittent  febrile  movement  last- 
ing for  many  months  may  precede  the  other  symptoms;  before  the  nodules 
develop  there  are  often  areas  of  erythematous  redness  upon  the  skin;  their 
edges  are  well-defined  and  there  may  be  cutaneous  hypersesthesia;  pigment 
may  be  deposited  in  these  spots,  which  may  later  disappear,  without  the 
development  of  nodules,  leaving  white  anaesthetic  areas  {lepra  alba).  More 
commonly  the  tubercular  nodules  appear  and  persist,  it  may  be,  for  years; 
ultimately  they,  for  the  most  part,  ulcerate,  but  some  may  disappear  without 
undergoing  this  process.  The  occurrence  of  nodular  growths,  in  the  face, 
together  with  the  cicatrized  areas  may  give  rise  to  the  appearance  termed 
the  fades  leontina;  at  times  the  nose  and  ears  may  ulcerate  away  and  the 
breaking  down  of  nodules  in  the  cornea  or  larynx  may  cause  blindness  or 
loss  of  voice.  Obstruction  to  respiration  and  even  death  may  be  caused  by 
tubercles  in  the  nose,  pharynx,  or  larynx.  Inhalation  pneumonia  is  not 
infrequent. 

b.  AncBsthetic  leprosy  is  evidenced  by  pains  in  the  limbs,  hypersesthesia 
or  numbness;  the  infiltrated  nerves  may  be  palpable  under  the  skin  and 
while  at  first  tender,  later  become  anaesthetic.  Trophic  disorders  such  as 
dryness  or  smoothness  of  the  skin  or  the  appearance  of  small  bullae  may  be 
noted.  Areas  of  cutaneous  anaesthesia  appear  and  may  be  preceded  by 
maculae  which  later  disappear.  Vesicles  form  which  burst  leaving  ulcers 
behind  and  the  trophic  disturbances  may  result  in  wasting  and  atrophy  of  the 
limbs  and  even  the  dropping  off  of  fingers  or  toes.  The  disease  may  last  for 
years  without  impairing  the  patient's  functions  but  the  increasing  exhaustion 
finally  overcomes  him. 

The  diagnosis  of  an  advanced  instance  of  either  type  is  very  simple.  In 
the  earlier  stages  the  areas  of  erythema  with  sensory  disturbance  are  quite 
typical.  In  doubtful  instances  a  section  of  the  skin  or  of  a  tubercle  should  be 
examined  for  the  presence  of  the  bacillus  lepra. 

The  prognosis  is  not  favorable  as  regards  recovery,  although  this  has 
occurred  in  the  anaesthetic  type,  with,  however,  persistent  trophic  lesions. 
The  course  of  the  disease  is  chronic,  lasting  even  20  or  30  years;  it  is  more 
rapid  in  the  ulcerative  variety.  Death  may  take  place  from  intercurrent 
disease  or  from  the  progressively  increasing  weakness. 

Treatment.  Isolation  or  segregation  should  be  insisted  upon  in  all 
instances.  This  is  preferable  to  the  legalized  compromise  which  obtains  in 
Norway;  here  the  indigent  lepers  are  cared  for  in  an  institution  while  those 
whose  income  is  sufficient  are  permitted  to  remain  at  home  under  proper  care 


LEPROSY.  221 

and  restrictions.  A  leprous  mother  should  not  nurse  her  infant  and  it  should 
associate  with  her  as  little  as  possible. 

Treatment  proper  consists  in  attention  to  cleanliness,  general  hygiene 
and  surroundings  and  the  administration  of  plenty  of  nourishing  food;  cer- 
tain observers  consider  that  a  diet  too  rich  in  carbohydrates  and  poor  in 
proteids  is  a  factor  in  the  causation  of  the  affection,  consequently  it  would 
seem  well  to  prescribe  a  regimen  containing  plenty  of  nitrogenous  food. 
The  internal  administration  of  chaulmoogra  oil  often  causes  marked  benefit. 
It  may  be  given  in  beginning  dose  of  5  minims  (0.33)  morning  and  evening, 
the  dose  being  increased  daily  by  from  4  to  6  minims  (0.24  to  0.40)  until  the 
patient  is  taking  as  much  as  250  minims  (16.0)  daily  in  3  or  4  doses.  The 
drug  may  be  given  in  milk,  hot  tea  or  in  capsules  and  should  be  continued 
for  2  to  3  months.  If  gastric  disturbance  is  caused  the  oil  may  be  given  per 
rectum,  2  drachms  (8.0)  in  milk  being  the  proper  quantity,  or  it  may  be 
administered  hypodermaticaUy  in  daily  dosage  of  from  i  to  2  drachms  (4.0 
to  8.0).  '  An  efficient  substitute  for  chaulmoogra  oil  is  sodium  gynocardate 
which  may  be  given  in  pill  form;  20  to  80  grains  (1.33  to  5.33)  may  be 
given  daily.     Gurjun  oil  is  at  present  little  used. 

Encouraging  results  have  been  reported  from  the  hypodermatic  employ- 
ment of  mercury  bichloride  and  sodium  chloride,  each  \  grain  (0.016)  in  20 
minims  (1.33)  of  distilled  water.  This  solution  is  injected  deeply  into  the 
muscles  twice  a  week.  Ichthyol  is  recommended  in  tubercular  leprosy  and 
may  be  given  in  doses  of  ^  a  drachm  to  2 J  drachms  (2.0  to  lo.o)  daily. 
Large  doses  of  potassium  iodide  may  be  given  in  the  hope  of  causing  the 
erythematous  nodes  to  disappear.  Other  drugs  from  which  favorable  results 
have  been  obtained  are  sodium  salicylate,  potassium  chlorate  and  sodium 
cacodylate.  Calmette's  antivenene,  given  hypodermaticaUy  in  doses  of  5  to  7 
drachms  (20.0  to  28.0),  has  been  administered  with  benefit  in  certain 
patients.     The  injections  are  given  every  2  days  at  first,  then  daily. 

Locally  inunctions  of  p}Togallic  and  chrysophanic  acid  and  of  20  percent, 
salicylic  acid  have  been  recommended.  The  nodules  before  ulceration  may 
be  cauterized  with  the  thermo-  or  galvano-cautery  after  which  powders,  such 
as  thymol  iodide  or  iodoform,  may  be  applied.  The  latter  should  also  be 
dusted  upon  ulcerations  or  a  i  to  20  phenol  ointment,  5  percent,  europhen 
(an  organic  iodine  compound)  in  olive  oil  or  i  part  of  gurjun  oil  to  2  parts 
of  lime  water  may  be  employed. 

The  frequent  application  to  the  nasal  and  buccal  cavities  of  mild  antiseptic 
solutions  and  of  10  to  20  percent,  silver  nitrate  to  ulcerations  of  mucous  sur- 
faces is  to  be  advised. 

The  neuralgic  pains  may  be  controlled  by  the  administration  the  coal  tar 
analgesics,  aconitine  or  gelsemine.  Nerve  stretching  may  be  advisable  in 
extreme  instances. 


2  22  THE    INFECTIOUS    DISEASES. 

Very  recently  excellent  results  have  been  reported  as  following  the  treat- 
ment of  leprosy  by  means  of  the  X-ray.  At  least  one  patient  seems  to  have 
been  cured  since  the  presence  of  the  bacilli,  easily  demonstrable  before  ex- 
posure to  the  rays,  have  disappeared  as  a  result  of  their  application,  and 
improvement  in  a  number  of  other  patients  has  been  noted;  whether  the 
results  are  permanent,  time  alone  will  tell.  Wilkinson  who  makes  the 
report  believes  that  when  a  lesion  is  treated  the  organisms  in  that  situation 
are  killed  and  their  bodies  are  absorbed,  producing  an  immunity  against 
the  living  organism.  The  part  which  presents  the  greatest  involvement  is 
selected  and  exposed  to  the  ray  usually  for  lo  minutes  at  a  distance  of  from  7 
to  10  inches.  The  effort  is  made  to  approach  as  near  to  burning  the  skin  as 
possible  without  actually  doing  so.  After  two  or  three  treatments  a  blushing 
of  the  skin  is  noticed  and  there  is  a  sensation  of  itching.  Of  the  three 
patients  in  which  the  result  was  considered  to  be  successful  in  two  the  treat- 
ments were  fourteen  in  number,  in  the  third,  fifty-two. 

Recently  rather  remarkable  results  have  been  reported  as  due  to  the  admin- 
istration of  a  fluid  extract  of  mangrove  {rhizophora  mangle).  At  first  2 
drachms  (8.0)  are  given  morning  and  evening,  later  this  dosage  is  increased 
to  from  2  to  3  ounces  (60.0  to  90.0)  daily.  Each  night  the  patient  is  given  a 
bath  at  102^  to  104°  F.  (38.9°  to  40°  C.)  to  which  enough  mangrove  decoction 
has  been  added  to  redden  the  water.  A  light  diet,  chiefly  of  fruit  and  milk, 
is  prescribed  together  with  tonics  such  as  coca  and  kola;  no  acids  nor  spices 
are  allowed.  The  patient  is  advised  to  sleep  in  a  cool  room  and  to  avoid  the 
hot  sun.  Ulcers,  if  they  appear,  are  dressed  with  30  percent,  of  the  fluid 
extract  of  the  mangrove  in  water. 

FRAMBCESIA. 

Synonym.     Yaws. 

Definition.  A  chronic  contagious  disease  chiefly  observed  in  the  tropics 
and  characterized  by  the  development  of  granulation  tissue  in  the  true  skin. 

./Etiology.  This  affection  is  common  in  Africa,  Southern  Asia  and  the 
islands  of  the  Pacific.  In  the  West  Indies,  Central  and  South  America  it 
is  less  frequent.  It  is  rarely  met  in  the  United  States.  Dark  skinned  races 
are  more  frequently  attacked  than  whites  and,  while  yaws  may  occur  at  any 
age,  children  are  most  frequently  affected.  Wliile  probably  of  bacterial 
origin,  the  specific  micro-organism  of  the  infection  has  not  been  isolated. 
The  disease  is  transmissible  by  direct  inoculation  through  an  abrasion  of 
the  skin  and  also  by  food  and  eating  and  cooking  utensils. 

Symptoms.  The  period  of  incubation  varies  from  2  to  8  weeks.  Pro- 
dromal symptoms  such  as  malaise,  anorexia,  headache  and  pains  in  the 
muscles  and  joints,  may  be  present,  particularly  in  children,  during  this 
period.     The  invasion  of  the  disease  is  marked  by  the  appearance  of  the 


VERRUGA. 


223 


primary  sore  which  in  experimental  yaws  appears  at  the  site  of  inoculation. 
This  is  at  first  a  small  papule  which  within  about  seven  days  becomes  a 
shallow  ulcer  which  in  turn  soon  heals  leaving  an  indurated  scar.  The 
primary  lesion  may  be  wanting  in  certain  instances.  With  the  initial  sore 
the  secondary  eruption  may  appear  or,  more  usually,  it  is  several  weeks  before 
its  occurrence.  It  may  be  preceded  by  a  pallor  of  the  skin  with  a  bran-like 
desquamation. 

The  secondary  rash  appears  first  on  the  face  and  soon  spreads  to  other 
parts.  It  consists  of  small  papules  which  are  particularly  numerous  near 
the  muco-cutaneous  junctions.  The  papules  enlarge  forming  tubercles  under 
the  skin  as  large  as  a  good  sized  pea;  at  the  top  of  these  pustulation  soon 
commences,  and  the  skin  breaking,  a  yellowish  fluid  is  discharged  which  dries, 
forming  a  tough  firm  crust,  under  which  the  tissue  is  papillomatous,  resembling 
a  raspberry  in  appearance.  From  this  raw  surface  there  is  an  exudation  of 
viscid 'yellowish  pus.  Pain  is  seldom  present  but  there  is  usually  an  annoy- 
ing pruritus.  Successive  crops  of  the  lesions  may  appear  and  after  several 
months  they  diminish  in  size  and  scab  over,  the  crust  ultimately  falling  and 
leaving  behind  a  spot  of  increased  pigmentation  in  whites  and  of  skin  lighter 
than  the  normal  in  dark  races.  In  prolonged  and  untreated  instances  a  third 
stage  may  occur,  characterized  by  breaking  down  of  the  nodules,  pains  in  the 
bones  and  joints,  periostitis  and  bone  caries. 

The  diagnosis.  Yaws  is  to  be  distinguished  from  syphilis,  to  which  it 
bears  so  close  a  resemblance  that  certain  observers  consider  them  the  same 
or  at  least  analogous  diseases,  by  the  lack  of  induration  in  the  initial  sore, 
of  gland  enlargement,  of  secondary  involvement  of  the  mucous  membranes 
and  of  vascular  thickening.  Verruga  bears  a  close  similarity  to  yaws  but  is 
histologically  a  distinct  disease. 

The  prognosis  is  usually  good. 

Treatment.  Isolation  of  all  patients  should  be  practised,  all  abrasions  of 
the  skin  should  be  properly  treated  and  protected,  and  buildings  in  which  pa- 
tients afflicted  with  the  disease  have  lived  should  be  avoided.  Constitutional 
treatment  consists  in  the  administration  of  potassium  iodide;  general  tonic 
treatment,  iron,  arsenic,  etc.,  are  often  necessary  adjuvants.  The  external 
lesions  should  be  kept  clean  by  the  application  of  antiseptics  and,  when 
advisable,  should  be  protected  by  dressings.  Sluggish  ulcers  should  receive 
stimulation  by  means  of  silver  nitrate  and  balsam  of  Peru  and  the  chronic 
nodules  may  be  treated  surgically. 

VERRUGA. 

Synonyms.     Peruvian  Warts;  Verruga  Peruviana. 

Definition.     A  chronic   infectious  disease  characterized  by  a  prodromal 


2  24  THE    INFECTIOUS    DISEASES. 

febrile  stage,  rheumatic  pains  and  the  subsequent  development  of  granulo- 
matous wart-like  excrescences  upon  the  skin,  mucous  membranes  and 
viscera. 

.etiology.  This  disease  occurs  only  in  certain  parts  of  Peru  upon  the 
western  incline  of  the  Andes.  It  is  not  contagious  but  is  inoculable  and  may 
appear  in  epidemics.  The  natives  believe  that  it  is  contracted  by  drinking 
the  water  of  certain  springs.  It  attacks  all  ages  and  both  sexes  and  seems 
to  be  intimately  associated  with  a  pernicious  type  of  malaria  knovvn  as  "  Oroya 
Fever."  Its  specific  cause  is  unknown  but  a  bacillus  somewhat  larger  than 
the  tubercle  bacillus  has  been  held  responsible  by  Yzquierdo.  One  attack 
usually  confers  immunity. 

Symptoms.  After  an  incubation  period  of  from  2  weeks  to  40  days  the 
invasion  of  the  disease  takes  place;  prodromata,  such  as  malaise,  and  a 
tired  sensation  in  the  limbs,  persist  for  a  few  days  and  are  succeeded  by  an 
afternoon  rise  of  temperature.  The  latter  becomes  gradually  more  marked 
and  may  be  either  remittent  or  intermittent  in  type.  There  are  chills  and 
pains  in  the  joints  of  the  extremities  and  in  the  spine;  the  pain  is  more  severe 
at  night  and  attacks  one  articulation  after  another.  Muscular  contraction 
involving  the  sterno- mastoid  and  calf  muscles  may  be  observed.  The  patient 
loses  flesh  and  becomes  anaemic,  there  is  hepatic  and  splenic  enlargement. 

After  about  3  weeks  the  eruption  appears  and  with  its  incidence  an  amelio- 
ration of  the  other  symptoms,  including  the  fever,  occurs.  The  rash  shows 
itself  first  upon  the  face,  the  extremities  and  about  the  joints,  the  hairy  parts 
are  involved  but  rarely  the  trunk;  it  begins  as  small  pinkish  spots,  soon  becom- 
ing papular  and  dark  red  or  bluish  in  color.  The  papules  vary  in  number 
from  only  a  few  to  several  hundred  and  in  size  from  that  of  a  small  pea  to  that 
of  an  orange;  they  are  vascular  and  bleed  easily.  "When  occurring  upon  the 
internal  organs  they  may  cause  difficulty  in  swallowing  and  bleeding  from 
the  oesophagus,  stomach,  bowel,  bladder  or  uterus.  The  growths  persist 
for  several  months  and  either  dry  into  black  spots  which  disappear  leaving  no 
trace,  ulcerate  or  suppurate. 

The  prognosis  is  much  more  favorable  in  the  natives  than  in  whites,  the 
mortality  varying  from  about  10  percent,  in  the  former  to  70  percent,  in  the 
latter.  An  early  incidence  of  the  eruption  augurs  a  favorable  course  and 
outcome,  but  delayed  and  atypical  outbreaks  signify  a  severe  type  of  the 
disease. 

Treatment.  The  removal  of  the  patient  to  the  lower  levels  near  the  sea 
is  always  to  be  advised  and  quinine  should  be  administered  on  account  of  the 
possibility  of  a  malarial  element  in  the  infection.  Tonics  and  stimulants 
are  often  necessary  and  the  ulcerous  and  suppurative  excrescences  should 
receive  antiseptic  treatment.  In  other  regards  the  treatment  is  supportive 
and  symptomatic. 


MEASLES.  225 


MEASLES. 


Synonyms.     Rubeola;  Morbilli. 

Definition.  An  acute  infectious  febrile  disease,  often  occurring  in  epidem- 
ics, and  characterized  by  congestion  of  the  upper  air  passages  and  a  dusky 
red  eruption  of  maculo-papular  form. 

Etiology.  The  disease  is  commonly  endemic,  epidemics  occurring  in 
most  thickly  populated  districts  about  every  2  years.  It  prevails  chiefly 
during  the  cold  months  and  appears  usually  in  children,  but  adults  may  be 
attacked.  Infants  under  3  months  seem  to  possess  a  certain  degree  of  immun- 
ity. Measles  is  almost  certain  to  be  communicated  to  those  not  rendered 
immune  by  previous  attacks  and^  when  introduced  into  regions  where  the 
disease  has  previously  been  unknown,  is  extremely  fatal. 

The  specific  cause  of  measles  is  undoubtedly  a  micro-organism,  but,  while 
various  bacteria  have  been  found  in  the  secretions  of  sufferers,  none  of  these 
has  been  proven  to  be  directly  causative  of  the  infection.  The  contagium 
is  given  off  in  the  conjunctival,  nasal  and  bronchial  secretions  and  these  are 
infective  even  before  the  stage  of  eruption.  Dried  particles  of  the  secretions 
may  collect  upon  clothing,  furniture,  etc.,  the  latter  thus  becoming  capable 
of  transmitting  the  infection.     The  contagium  is,  however,  short  lived. 

One  attack  usually,  but  not  always,  confers  immunity.  While  mistaken 
diagnoses  are  responsible  for  many  apparently  repeated  attacks,  it  is  undoubt- 
edly true  that  susceptible  individuals  may  suft'er  from  the  infection  more 
than  once. 

Pathology.  The  post  mortem  appearances  in  measles  are  in  no  way  char- 
acteristic. The  catarrhal  condition  of  the  conjunctival  mucous  membranes 
is  not  distinctive.  Death  is  usually  due  to  complications,  especially  broncho- 
pneumonia, and  the  tv'pical  lesions  ordinarily  found  in  this  condition  are 
present.  Lobar  pneumonia  with  collapse  of  the  lung  may  be  found  and 
sweUing  of  the  lymphatic  tissues  throughout  the  body,  tonsils,  lymph  nodes, 
and  intestinal  follicles,  may  occur.  There  may  be  slight  splenic  enlargement. 
In  instances  of  malignant  or  black  measles  haemorrhages  are  present. 

Symptoms.  The  incubation  period  is  from  7  to  14  days,  rarely  a  few  days 
longer.  Prodromata  such  as  malaise,  sneezing  and  feverishness  may  be  noted 
at  the  end  of  this  period.     Leucocytosis  may  be  present. 

The  period  of  invasion  lasts  3  or  4  days,  during  which  the  symptoms  of 
conjunctivitis  and  rhinitis  are  noted.  The  onset  may  be  gradual  or  sudden 
and  marked  by  chilly  feelings — rarely  a  distinct  chill — or  a  con\ailsion.  The 
fever  at  first  is  not  very  high  and  may  remit  upon  the  2d  day.  Following  this 
the  temperature  rises  to  104°  to  105°  F.  (40°  to  40.5°  C).  Other  symptoms 
of  the  onset  are  cough,  nausea  and  vomiting.  The  pulse  is  rapid  and  full. 
As  the  fever  falls  the  pulse  returns  to  normal. 
15 


226 


THE    INFECTIOUS    DISEASES. 


The  symptoms  continue  for  about  4  days  and  in  severe  infections  cerebral 
manifestations  may  be  present.  On  the  4th  day  the  t}'pical  eruption  appears. 
This  consists  of  maculo-papules,  at  first  rounded,  rose-colored  and  slightly 
elevated,  later  tending  to  coalesce  into  crescentic  shapes.  The  rash  appears 
first  upon  the  face  and  mucous  membranes,  then  upon  the  body,  the  extrem- 
ities becoming  finally  involved.  At  first  the  papules  impart  a  shot-like 
feeling  to  the  finger  and  may  be  mistaken  for  the  eruption  of  smallpox.  The 
rash  disappears  on  pressure,  is  fully  developed  in  from  2  to  4  days  and  then 


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Fig.  8. — Clinical  chart  of  measles  showing  defervescence  by  lysis  when  the  eruption 

is  fully  developed. 


gradually  fades.  In  from  10  to  14  days  fine  desquamation,  lasting  from  a 
few  days  to  several  v^reeks,  takes  place.  At  the  height  of  the  eruption  there 
may  be  enlargement  of  the  glands  of  the  neck. 

A  day  or  two  before  the  eruption  small  red  spots  from  the  size  of  a  pin  head 
to  that  of  a  split  pea  appear  on  the  lining  of  the  cheeks  and  mouth.  At 
the  center  of  these  is  a  bluish-white  spot  which  may  be  made  out  with  the 
aid  of  a  strong  light.  The  white  spots  may  be  removed  by  means  of  a  forceps 
and,  being  examined,  are  shown  to  consist  of  epithelial  cells  in  a  state  of  fatty 
degeneration.  These  are  known  as  Filatov's  or  KopHk's  spots  and  are  an 
important  early  diagnostic  sign. 

The  symptoms  of  the  disease  continue  until  the  eruption  has  reached  its 
height.  On  the  5th  or  6th  day  it  begins  to  fade,  the  temperatiire  begins  to 
fall  gradually  and  the  symptoms  become  ameliorated. 

Variations  from  the  typical  course  may  take  place.     Morbilli  sine  morhillis 


MEASLES.  227 

is  the  term  applied  to  the  disease  when  the  symptoms  are  manifested  but  no 
eruption  appears.  A  mild  type,  in  which  all  the  symptoms  are  slight  and 
recovery  takes  place  within  a  few  days,  has  been  described.  Malignant  or 
black  measles  is  a  severe  and  fatal  type,  characterized  by  haemorrhages  into 
the  skin  and  from  the  mucous  membranes,  here  the  prostration  is  marked 
and  all  the  signs  of  a  severe  toxaemia  are  present. 

Complications.  It  is  these  which  render  measles  a  disease  to  be  dreaded. 
Broncho-pneumonia  is  the  most  common  and  may  be  diagnosticated  by  the 
persistence  of  the  cough  and  high  temperature  and  by  the  physical  signs  of 
small  areas  of  pulmonary  consolidation.  Lobar  pneumonia  may  also  com- 
plicate the  disease.  Less  frequent  complications  are  otitis  media,  laryngitis, 
diphtheria,  ulcerative  or  gangrenous  stomatitis,  keratitis  and  parotitis.  Neph- 
ritis, endocarditis  and  joint  inflammations  and  nervous  complications,  while 
fortunately  rare,  have  been  observed.  Among  these  may  be  mentioned 
hemiplegia,  paraplegia,  meningitis,  multiple  neuritis  and  cerebral  abscess. 

Pulmonary  tuberculosis  may  develop  as  a  sequel  of  measles  and,  in  patients 
of  suspicious  diathesis,  when  the  cough  is  obstinate,  this  possibility  should 
not  be  forgotten.  Diphtheria  is  not  an  uncommon  complication  in  institu- 
tions. 

The  diagnosis  of  measles  during  epidemics  is  not  difficult.  Early  in  the 
affection  the  appearance  of  the  spots  upon  the  buccal  mucous  membrane 
is  an  aid  in  differentiation.  The  early  involvement  of  the  nasal  lining  and 
the  conjunctiva  as  against  the  sore  throat  and  enlarged  glands  of  scarlatina 
should  aid  in  differentiation  from  the  latter  disease.  Fever  for  4  or  5  days, 
accompanied  by  catarrhal  symptoms,  buccal  spots  and  the  appearance  at 
the  end  of  this  period  of  a  maculo-papular  rash,  tending  to  become  crescentic, 
should  differentiate  from  chicken-pox  and  German  measles. 

The  prognosis  in  uncomplicated  instances  which  occur  amid  good  sur- 
roundings is  favorable,  provided  the  patient's  general  condition  is  good.  In 
epidemics  under  unsanitary  conditions  as  in  asylums,  army  camps,  etc.,  the 
disease  is  likely  to  be  attended  by  a  high  death  rate. 

Poorly  nourished  patients  and  those  affected  with  previous  chronic  disease 
are  very  prone  to  comphcations,  especially  pneumonia,  and  in  this  event  sel- 
dom recover. 

Treatment.  Prophylaxis  consists  in  immediate  isolation  and  the  removal 
of  other  children  from  the  house.  The  latter  should  be  kept  from  associa- 
tion with  other  children  for  at  least  2  weeks  in  order  that  the  disease,  if  con- 
tracted, may  develop. 

Many  parents  encourage  their  children  to  expose  themselves  on  the 
principle  that  every  one  must  contract  the  disease  and  that  it  is  less  likely 
to  prove  serious  in  childhood  than  in  adult  life,  but  this  is  little  less  than 
criminal. 


228  THE    INFECTIOUS   DISEASES. 

All  discharges,  dressings,  clothing,  the  sick-room,  etc.,  should  be  disinfected 
according  to  the  usual  methods.  The  contagium  of  measles  being  of  feeble 
vitality  the  quarantine  need  be  kept  up  not  longer  than  4  or  5  weeks. 

Measles  is  a  self-limited  disease  and  unfortunately  we  have  no  means  of 
aborting  it  or  shortening  its  course.  Its  treatment,  therefore,  is  symptomatic 
and  supportive;  much  also  can  be  done  in  the  way  of  preventing  the  incidence 
of  complications. 

At  the  onset  of  the  disease  the  patient  should  be  put  to  bed  in  a  darkened 
room  and  isolated.  The  apartment  should  be  well  ventilated  and,  while 
its  temperature  need  not  be  high,  the  patient  should  be  carefully  protected 
from  draughts.  The  bed  covering  need  not  be  heavy  but  should  be  sufficient 
to  keep  the  patient  comfortable.  The  bowels  should  be  opened  at  the  invasion 
of  the  disease  by  means  of  fractional  doses  of  calomel  followed  by  a  saline 
and  they  should  be  kept  open  throughout  the  disease  by  means  of  laxatives. 
The  skin  should  be  kept  active  and  the  kidneys  mildly  stimulated  by  the 
simpler  alkaline  diiu-etics  or  spiritus  astheris  nitrosi.  The  conjunctivitis 
may  be  controlled  by  means  of  the  application  of  cloths  moistened  in  cold 
water  or  by  dropping  a  few  minims  of  saturated  solution  of  boric  acid  into 
the  eyes  at  intervals.  The  lids  may  be  prevented  sticking  together  by  smearing 
their  edges  lightly  with  vaseline.  Should  the  conjunctivitis  become  purulent 
a  few  drops  of  a  5  percent,  solution  of  silver  vitellin  (argyrol)  should 
be  instilled  at  frequent  intervals.  The  care  of  the  nose  and  pharynx 
is  most  important  since  it  is  by  extension  from  these  parts  that  the 
middle-ear  frequently  becomes  involved.  The  nasal  cavity  and  the 
throat  should  be  frequently  sprayed  with  diluted  liquor  antisepticus 
(U.  S.  P.).  Following  the  cleansing  influence  of  these  alkaline  applica- 
tions the  inflammatory  condition  of  the  mucous  membranes  may  be 
relieved  by  spraying  with  albolene,  to  an  ounce  (30.0)  of  which  about 
10  drops  (0.66)  of  eucalyptol  or  thymol  or  both  have  been  added.  The 
itching  and  burning  of  the  skin  may  be  relieved  by  sponging  with  tepid  water 
to  which  a  little  sodium  carbonate  has  been  added  or  by  rubbing  in  vaseline 
or  oleum  theobromatis.  The  fever  ordinarily  needs  no  especial  treatment; 
should  it  rise  to  104°  F.  (40°  C.)  or  over  it  may  be  controlled  by  sponging 
with  cool  water  or  by  small  doses  of  antip^Tine  or  acetphenetidine.  In  the 
early  stages  this  symptom  may  be  relieved  by  small  doses  of  tincture  of 
aconite — 3  to  5  drops  (0.2  to  0.33) — every  2  or  3  hours.  If  this  drug  is  given 
the  pulse  should  be  watched  and  the  medication  should  be  stopped  at  once 
if  any  sign  of  cardiac  depression  is  noted.  The  cerebral  symptoms  may  be  re- 
lieved by  cool  sponging  or  cool  packs  and  by  the  application  of  an  ice  cap  to 
the  head,  but  when  the  pulse  is  weak  and  the  extremities  are  cold  and  cyanotic, 
warm  baths  with  the  addition  of  mustard  are  indicated.  Stimulation  may 
be  necessary,  especially  if  pneumonia  is  present  as  a  complication  and  here 


RUBELLA.  229 

small  doses  of  alcohol  or  strychnine  should  be  employed.  In  collapse  the 
hypodermatic  administration  of  camphor  in  £ether  or  oil  is  useful. 

For  the  bronchitis  simple  cough  mixtures  containing  expectorants  such  as 
ammonium  chloride  or  ipecac  in  small  doses,  with  the  addition  of  codeine 
or  heroine  if  the  cough  is  distressing,  should  be  prescribed.  In  order  to 
prevent  broncho-pneumonia  it  is  necessary  that  the  patient  have  a  plentiful 
supply  of  fresh  air  and  yet  that  all  chances  of  exposure  should  be  studiously 
avoided.  A  flannel  jacket  should  be  fitted  to  the  chest,  the  skin  of  which 
should  be  daily  rubbed  with  oHve  oil  to  which  a  little  tiirpentine  or  camphor 
may  be  added  if  desired.  The  administration  of  guaiacol  carbonate  is  advo- 
cated in  the  treatment  of  the  catarrhal  manifestations  of  measles  as  being 
preventive  of  respiratory  complications. 

The  various  complications  should  be  treated  as  when  occurring  independ- 
ently. In  institutions  the  occurrence  of  diphtheria  as  a  complication  may 
be  prevented  by  the  administration  of  an  immunizing  dose  of  antitoxin  to 
each  instance.  According  to  Holt  this  procedure  has  been  carried  out  with 
excellent  results. 

In  instances  when  the  eruption  is  delayed  the  patient  should  be  given  a 
hot  pack  by  means  of  a  blanket  wrung  out  in  hot  water.  This  should  be 
wrapped  about  him  and  then  covered  by  a  rubber  sheet.  This  procedure 
induces  profuse  perspiration  and  the  appearance  of  the  rash. 

The  diet  during  the  febrile  period  should  be  entirely  fluid,  consisting  of 
milk,  soups  and  broth.  When  the  fever  has  subsided  a  gradual  return  to 
an  ordinary  regimen  may  be  allowed. 

The  patient  should  remain  in  bed  for  about  a  week  after  the  temperature 
has  reached  normal  and  must  not  be  allowed  to  use  his  eyes  for  about  a  month. 
While  desquamation  is  taking  place  the  skin  should  be  kept  soft  by  means 
of  inunctions  of  oil  or  cocoa  butter.  For  considerable  time  after  convales- 
cence has  become  established  the  patient  should  be  kept  from  exposure  to 
sudden  changes  of  temperature;  particularly  is  this  necessary  if  there  is  per- 
sistence of  the  cough.  Here  the  administration  of  codliver  oil  and  creosote 
carbonate  is  indicated  and  a  change  of  climate  is  to  be  advised,  preferably 
to  one  of  high  altitude,  slight  humidity  and  mild  temperature.  In  ordinary 
instances  tonics  should  be  administered  during  convalescence  and  the  diet 
should  be  plentiful,  nourishing  and  easily  digestible. 

RUBELLA. 

Synonyms.     Rotheln;  German  Measles;  Roseola. 

Definition.  An  acute  infectious  febrile  disease  of  mild  type  accompanied 
by  a  maculo-papular  eruption  and  enlargement  of  the  cervical  lymph  nodes 
and  at  times  by  mild  catarrhal  symptoms. 


230  THE    INFECTIOUS   DISEASES. 

Etiology.  That  this  disease  is  distinct  from  measles  and  scarlet  fever 
has  been  definitely  proven.  It  occurs  chiefly  in  children,  although  it  may  be 
contracted  by  adults.  It  is  very  contagious,  although  rather  less  so  than 
measles  and  appears  both  epidemically  and  sporadically.  The  infection 
is  probably  microbic  in  origin  but  as  yet  its  specific  cause  has  not  been 
isolated.  The  contagium  is  transmitted  by  direct  contact  with  the  patient 
and  by  fomites  and  is  probably  active  from  the  beginning  of  the  disease 
until  well  into  the  convalescent  period.  One  attack  usually  confers  im- 
munity. 

Symptoms.  The  period  of  incubation  is  from  i  to  3  weeks,  averaging  about 
10  days  and  while  there  are  often  no  prodromata,  for  a  period  of  2  or  3 
days  before  the  appearance  of  the  eruption  the  patient  may  complain  of  chilly 
sensations,  general  pains  and  malaise,  sore  throat  and  slight  fever.  Mild 
bronchitis,  tonsillar  and  glandular  swelling  in  the  cervical  region  may  be 
present.  Slightly  before  or  synchronous  with  the  appearance  of  the  rash, 
which  may  be  the  initial  symptom,  the  temperature  rises  to  100°  to  103°  F. 
(37.8°  to  39.4°  C).  The  eruption  appears  first  upon  the  face  and  spreads 
thence  to  the  neck,  trunk  and  extremities.  At  times  it  is  confined  to  one 
part  while  at  others  it  involves  the  whole  cutaneous  surface  including  the  palms, 
soles  and  buccal  lining.  The  rash  is  papular,  rose-colored  and  may  become 
confluent,  the  papules  fusing  irregularly,  while  the  surrounding  skin  may 
become  hyperaemic.  The  papules  vary  in  size  but  are  smaller  than  those  of 
measles  and  do  not  fuse  in  crescentic  shapes.  When  the  eruption  involves  the 
various  parts  of  the  body  in  succession  it  is  seen  in  all  stages  at  the  same  time. 
In  other  instances  it  may  appear  upon  all  parts  simultaneously.  It  reaches 
its  height  within  from  24  to  48  hours  and  lasts  from  2  to  5  days  as  a  rule, 
when  it  may  terminate  in  slight  desquamation,  less  marked,  however,  than 
that  of  measles. 

Sore  throat  is  almost  always  present  and  swelling  of  the  cervical  glands, 
and  even  of  those  of  the  axilla  and  groin  may  occur.  Slight  catarrhal  symp- 
toms referable  to  the  mucous  membranes  of  the  eyes  and  nose  are  not  infre- 
quent. 

The  pulse  is  rapid  in  proportion  to  the  elevation  of  the  temperature;  the 
latter  falls  with  the  fading  of  the  rash  and  the  other  symptoms  gradually 
ameliorate. 

The  course  of  the  disease  is  from  3  to  7  or  8  days  and  convalescence 
is  rapid.  Relapses  may  occiu-  but  complications  are  seldom  seen.  Rarely 
a  complicating  bronchitis,  pneumonia,  or  digestive  disturbance  may  be 
observed. 

The  diagnosis  in  typical  instances  is  not  particularly  difficult.  In  instances 
indistinctly  characteristic  the  problem  is  less  simple.  Such  may  be  differ- 
entiated from  measles  by  the  absence  of  buccal  spots  and  marked  catarrhal 


SCARLATINA.  23 1 

symptoms,  by  the  mildness  of  onset,  lighter  colored  and  more  diffuse  eruption; 
from  scarlatina  by  general  mildness  of  course,  absence  of  severe  throat  involve- 
ment, atypical  tongue  and  absence  of  general  erythematous  eruption. 

The  prognosis  is  generally  most  favorable,  delicate  children,  those  whose 
surroundings  are  unhealthful  and  those  who  are  unfortunate  enough  to  be 
subjected  to  complications  may  succumb  to  the  disease. 

Treatment.  The  patient  should  be  strictly  quarantined  until  the  diag- 
nosis has  been  absolutely  assured.  Confinement  to  bed  should  be  enjoined 
and  fluid  diet  is  necessary  as  long  as  the  temperature  remains  elevated.  The 
bowels  should  be  opened  at  the  onset  of  the  disease  by  means  of  fractional 
doses  of  calomel  followed  by  a  saline  and  regular  daily  movements  should  be 
secured  by  mild  laxatives  or  simple  enemata  if  necessary.  The  skin  should 
be  kept  active  and  cleansed  by  means  of  a  daily  sponge  bath;  cool  bathing  may 
be  resorted  to  if  the  temperature  causes  anxiety.  The  catarrhal  symptoms 
should  be  treated  just  as  in  measles  and  if  there  is  cutaneous  irritation  this 
may  be  relieved  by  gently  inuncting  carbolized  vaseline  or  theobroma  oil. 
The  enlarged  glands  may  be  rubbed  with  a  5  percent,  ichthyol  or  compound 
iodine  ointment. 

The  complications  are  to  be  treated  as  when  they  occur  independently 
and  during  convalescence  the  administration  of  tonics,  such  as  iron,  strychnine 
and  codliver  oil,  may  be  advisable,  especially  in  debilitated  children. 

SCARLATINA. 

Synonym.     Scarlet  Fever. 

Definition.  An  acute  infectious  fever  characterized  by  a  diffuse  scarlet 
rash  upon  the  skin  and  usually  accompanied  by  pharyngeal  inflammation. 

.Etiology.  The  disease  occurs  endemically  in  nearly  all  parts  of  the 
world  and  amongst  all  races;  the  natives  of  East  India  and  of  Japan  are  said, 
however,  to  be  to  some  extent  immune  to  the  infection.  At  intervals  epidemics 
of  varying  intensity  appear.  The  disease  is  most  common  during  the  autumn 
and  winter  months  and  it  affects  chiefly  children  under  the  age  of  10  years. 
Certain  individuals  and  some  families  seem  to  be  insusceptible.  Nursing 
infants  seldom  contract  the  disease;  in  pregnancy  and  after  surgical  operations 
individual  susceptibility  is  increased. 

An  enormous  amount  of  work  has  been  done  upon  the  bacteriology  of 
scarlet  fever  but  up  to  the  present  time  the  results  have  been  inconclusive. 
In  the  majority  of  instances  the  streptococcus  pyogenes  is  to  be  found  in  the 
inflammatory  exudates  of  the  disease  but,  while  certain  observers  believe  this 
to  be  the  specific  cause  of  the  infection,  it  seems  more  probable  that  this  bacter- 
ium is  present  as  a  result  of  mixed  infection  and  that  the  true  cause  of  scarla- 
tina is  another  micro-organism.     Mallory  has  found  a  parasite  in  the  skin 


232  THE    INFECTIOUS   DISEASES. 

which  has  also  be^en  demonstrated  in  the  serum  of  blisters  by  Duval  and 
which  occurs  in  various  forms,  notably  in  the  shape  of  a  rosette,  resembling 
the  rosette  stage  in  the  reproductive  cycle  of  the  malarial  parasite.  Class, 
whose  researches  have  been  confirmed  by  others,  has  found  in  the  blood, 
urine,  scales  of  epidermis  and  in  cultures  from  the  throat  a  diplococcus  which 
may  have  some  influence  in  the  causation  of  the  infection. 

With  regard  to  the  bacteriology  of  scarlatina  it  may  be  definitely  stated 
that  the  streptococcus  is  an  important  influence  in  the  aetiology  of  the  septic 
manifestations  of  the  disease. 

The  contagium  is  much  more  resistant  than  that  of  measles,  much  less 
diffusible  and  less  prone  to  infect  those  exposed.  The  latter  fact  may  be  due 
either  to  a  natural  immunity  enjoyed  by  certain  individuals  or  to  a  peculiarity 
of  the  contagium. 

Mode  of  transmission.  The  contagium  is  probably  contained  in  the  secre- 
tions of  the  throat,  respiratory  tract  and  ear  and  in  the  particles  of  skin  exfoli- 
ated at  the  termination  of  the  disease.  The  disease  may  be  communicated 
by  direct  contact  with  a  patient  or  by  fomites,  the  infection  being  very  resistant 
and  remaining  viable  for  long  periods  in  clothing,  bed  linen,  books,  etc. 
While  the  disease  may  be  carried  by  a  third  person,  this  mode  of  conveyance 
is  rare.  Air  may  carry  the  infection  for  short  distances  and  it  may  also  be 
transmitted  by  means  of  milk  with  which  infected  persons  have  come  into 
contact. 

The  poison  usually  affects  the  throat  primarily,  having  been  taken  in  upon 
the  inspired  air.  It  may  also  enter  by  means  of  the  digestive  tract.  The 
fact  that  infants  have  been  born  while  manifesting  the  disease  at  all  stages 
would  show  that  the  infection  may  be  transmitted  by  means  of  the  blood. 
One  attack  usually,  but  not  always  confers  immunity. 

Pathology.  This  disease  presents  no  distinctive  morbid  changes.  The 
eruption  is  ordinarily  invisible  post  mortem  unless  it  is  haemorrhagic  in  char- 
acter. The  throat  exhibits  the  appearances  of  simple  follicular  or  ulcerative 
tonsillar  and  peri-tonsillar  inflammation  with  an  accompanying  lymphoid 
enlargement  or  even  abscess  formation  in  the  neck  in  the  more  severe  instances. 
The  viscera,  especially  the  kidneys,  are  the  seat  of  an  acute  degeneration  and 
may  contain  foci  of  necrosis.  The  pathology  of  the  various  complications 
does  not  materially  differ  from  that  of  these  conditions  when  they  occur 
independently. 

Symptoms.  The  incubation  period  varies  from  i  to  14  days  but  is  usually 
2  to  4.  The  invasion  takes  place  suddenly  or  after  a  short  prodromal  period, 
characterized  by  indefinite  rrialaise.  The  initial  symptom  is  usually  emesis; 
chills  or  convulsions  may  occur.  The  temperature  rises  rapidly  to  103°  to 
105°  F.  (39.5°  to  40.5°  C),  the  pulse  is  proportionately  rapid — no  to  130 — 
the  face  is  hot  and  flushed,  the  tongue  dry  and  the  throat  sore. 


SCARLATINA.  -  233 

The  eruption  appears  from  12  to  36  hours  after  the  onset  of  the  disease. 
The  whole  skin  is  flushed  and  scattered  over  it  are  numerous  tiny  red  points; 
these  may  occur  in  irregular  patches  or  they  may  be  widely  disseminated. 
The  rash  appears  first  upon  the  neck  and  shoulders  and  extends  rapidly; 
the  skin  of  the  whole  body  and  of  the  Hmbs  may  be  involved  within  48  hours. 
When  the  eruption  is  at  its  height  the  skin  becomes  almost  uniformly  red  and 
swollen,  particularly  upon  protected  parts.  The  redness  disappears  on  pres- 
sure but  returns  instantly  upon  its  removal.  Upon  the  face  the  rash  is  least 
apparent  and  usually  involves  only  the  forehead  and  cheeks,  the  skin  about 
the  nose  and  mouth  remaining  pale.  The  eruption  is  present  upon  the 
pharynx.  It  remains  at  its  height  from  i  to  3  days  and  gradually  fades  as 
the  temperature  falls.  Variations  of  the  eruption  are  not  infrequent.  In 
the  severe  types  of  the  infection  it  is  darker  in  color  and  haemorrhagic 
petechiae  may  be  present.  Vesicles  containing  turbid  fluid  may  appear 
(scarlatina  tniliaris).  The  skin  is  often  rough  to  the  touch  and  itching  and 
burning  may  be  present.  The  rash  usually  begins  to  fade  about  the  7th  to 
the  loth  day  and  desquamation,  lasting  several  weeks,  takes  place.  This 
exfoliation  may  be  so  slight  as  to  be  difficult  of  perception  after  a  poorly 
marked  rash  or,  foUowing  one  of  severe  type,  the  skin  of  the  fingers  and 
toes  may  come  away  in  the  form  of  moulds  and  the  bits  of  desquamated 
epidermis  may  be  numerous  and  of  considerable  size. 

The  tongue  is  at  first  red  at  the  tip  and  edge  with  a  whitish  coat  in  its  center 
through  which  the  enlarged  papillae  protrude  giving  the  so-called  "  strawberry" 
or  "  raspberry  "  appearance.  As  the  disease  continues  the  white  coating  is 
shed  and  the  tongue  is  left  red,  rough  and  even  more  like  the  surface  of  a 
strawberry  or  raspberry  than  before. 

The  pharynx  may  be  the  seat  of  a  mild  infla  mmation,  of  a  follicular  tonsil- 
litis or  of  a  severe  anginoid  condition  caused  by  infiltration,  ulceration  and 
even  pseudo-membranous  inflammation  of  the  pharyngeal  structures;  lym- 
phoid enlargement  and  involvement  of  the  cervical  tissues'  may  be  noted. 
There  sometimes  is  numbness  and  formication  of  both  hands  (Myers's  sign). 

The  initial  fever  varies  from  103°  to  106°  F.  (39.5°  to  41.1°  C),  or  even 
higher  and  continues  with  slight  morning  remissions  until  the  rash  begins  to 
fade  when  it  falls  by  lysis.  Hyperpyrexia  may  occur  in  severe  infections. 
The  pulse  is  rapid  in  proportion  to  the  height  of  the  temperature  and  the 
respirations  are  also  accelerated.  The  spleen  may  be  slightly  enlarged. 
The  urine  is  scanty,  hyper-acid,  high  colored  and  often  contains  a  trace  of 
albumin  and  a  few  casts.  This  should  cause  no  undue  alarm  as  the  urine 
is  likely  to  become  normal  once  more;  it  should,  however,  be  examined  daily 
since  nephritis  is  an  important  and  not  infrequent  complication.  Leucocy- 
tosis  may  be  present. 

The  duration  of  the  febrile  movement  of  an  ordinary  instance  of  scarlatina 


234 


THE    INFECTIOUS   DISEASES. 


is    from   3    or   4    days   to    2    weeks,   depending  upon   the  severity  of  the 
infection. 
Irregular  forms  of  the  disease  occur.     These  are  of  3  chief  classes: 

1.  Anginose  scarlatina  which  is  characterized  by  severe  pharyngeal  symp- 
toms; the  throat  is  markedly  swollen  and  dysphagia  is  present,  upon  the 
tonsils  there  is  a  pseudo-membranous  exudate  which  may  result  in  abscess 
formation  and  ulceration.  The  inflammation  may  extend  to  the  larynx, 
trachea,  and  bronchi,  and  is  almost  certain  to  reach  the  middle-ear  by  means 
of  the  Eustachian  tube.  The  disease  may  terminate  in  death  and  sloughing 
of  the  tissues  of  the  neck  is  not  an  unusual  occurrence. 

2.  Malignant  scarlatina  is  characterized  by  a  severe  toxaemia  which  may 


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overwhelm  the  patient  and  result  in  death  even  before  the  diagnosis  is  made. 
Hyperpyrexia  is  present,  the  pulse  is  very  rapid,  soon  becoming  weak,  the 
prostration  is  marked  and  the  cerebral  symptoms  are  profound.  Death  takes 
place  from  adynamia. 

3.  HcBmorrhagic  scarlatina  is  typified  by  the  appearance  of  extravasations 
of  blood  beneath  the  skin  and  mucous  membranes  resulting  in  epistaxis, 
haematemesis,  intestinal  haemorrhage,  hasmaturia,  etc.  This  form  of  the 
disease  is  usually  fatal. 

Complications.  Of  these  nephritis  is  the  most  important  and  perhaps 
the  most  frequent.  It  is  of  acute  type  and  must  not  be  confounded  with  the 
albuminuria  which  so  often  occurs  when  the  fever  is  at  its  height.     It  is 


SCARLATINA.  235 

usually  evidenced  by  the  appearance  of  albumin  and  casts  in  the  urine  but 
instances  have  been  noted  in  vi^hich  renal  changes  have  been  found  post  mor- 
tem when  no  symptoms  suggesting  nephritis  had  been  present.  The  condition 
is  probably  the  result  of  the  toxic  action  of  the  poison  of  the  infection  and 
occurs  in  several  forms:  a,  A  mild  type  with  slight  oedema  and  albuminuria 
and  a  few  casts;  b,  a  more  severe  type,  with  more  marked  oedema,  dark  urine 
with  more  abundant  albumin  and  casts  and  transudates  into  the  serous  cavities, 
resulting  in  death  with  maemic  symptoms,  chronic  nephritis  or,  as  a  rule, 
recovery;  c,  a  hsemorrhagic  type,  with  scanty  urine  containing  blood,  albumin 
and  numerous  casts.  Anuria  may  occur,  vomiting  and  convulsions  are  fre- 
quent; the  outcome  is  usually  rapidly  fatal  and  due  to  uraemic  poisoning. 

Endocarditis  is  not  rare.  This  may  persist  after  recovery  from  the  scarla- 
tina or  may  occur  in  a  malignant  form  which  is  usually  fatal.  Myocarditis 
and  pericarditis  are  less  frequent  but  are  complications  to  be  dreaded. 

Pleurisy,  empycema,  bronchitis  and  broncho-pneumonia  are  less  common 
complications. 

An  arthritis  may  occur  in  one  of  two  forms:  an  arthritis  similar  to  that  occur- 
ring in  other  infections  such  as  enteric  fever  or  gonorrhoea  and  involving 
several  joints  as  a  rule,  or  a  suppurative  inflammation  affecting  one  or  more 
articulations.     The  prognosis  is  good  in  either  type.  * 

Otitis  is  a  serious  and  not  uncommon  complication  and  is  the  result  of  the 
extension  of  the  throat  inflammation  through  the  Eustachian  tube  to  the 
middle-ear.  Perforation  of  the  tympanic  membrane  is  frequent  and  mastoid- 
itis with  all  possible  complications  may  follow.  Impairment  of  hearing  or 
complete  deafness  may  result. 

Adenitis  accompanied  by  glandular  enlargement  in  the  cervical  region 
is  very  common  and  may  go  on  to  abscess  formation  and  necrosis  in  the  deep 
tissues  of  the  neck. 

Complications  referable  to  the  nervous  system  are  rare  but  sometimes 
occur.  Of  these  the  most  important  is  chorea  which  may  be  associated  with 
the  arthritis  and  endocarditis.  Hemiplegia,  progressive  paralysis  and  cere- 
bral thrombosis  have  been  observed. 

The  diagnosis  of  scarlet  fever  is  usually  not  difiicult  in  tj^pical  instances. 
the  rash,  the  pharyngeal  symptoms  and  the  tongue  being  characteristic. 
Scarlatina  may  be  differentiated  from  measles  by  its  more  abrupt  invasion, 
the  presence  of  throat  symptoms,  the  absence  of  the  buccal  spots  and  catarrhal 
symptoms  and  the  desquamation;  from  rubella  by  its  more  severe  constitutional 
symptoms  and  characteristic  tongue;  from  diphtheria  by  its  eruption  and  by 
bacteriological  examination,  but  it  must  not  be  forgotten  that  the  two  infec- 
tions may  be  present  simultaneously;  from  drug  eruptions  by  the  presence  of 
constitutional  symptoms  and  sore  throat;  and  from  acute  exfoliative  dermatitis 
by  the  presence  of  the  characteristic  tongue  and  throat  symptoms.     In  der- 


236  THE    INFECTIOUS    DISEASES. 

matitis  the  desquamation  differs,  the  skin  being  thrown  off  in  crusts  and 
scales;  a  moist  surface  is  frequently  left. 

The  prognosis  is  variable.  In  some  epidemics  the  mortality  is  high,  but 
as  a  rule  the  death  rate  in  this  disease  is  not  great.  It  is  higher  in  infants 
and  in  institutions.  The  malignant  and  fulminating  instances  are  fortunately 
not  common  for  they  are  almost  certainly  fatal.  Complications  are  usually 
responsible  for  death  when  this  occurs  in  the  ordinary  type  of  the  disease. 
Relapses  in  scarlatina  are  rarely  observed. 

Treatment.  Prophylaxis  is  most  important  for  by  proper  methods  the 
disease  may  be  to  a  great  extent  prevented.  Isolation  during  the  course  of 
the  disease  and  thorough  disinfection  of  the  sick-room  and  its  contents  are 
absolute  essentials.  The  physician  should  always  cover  his  ordinary  clothing 
with  a  long  gown  while  visiting  the  patient  and  upon  leaving  should  disinfect 
his  hands  and  his  face  and  hair  in  so  far  as  is  possible.  Only  the  persons 
immediately  concerned  in  the  care  of  the  patient  should  be  allowed  in  the 
sick-room,  all  the  excreta  should  be  rigidly  disinfected  and  the  skin,  especially 
during  desquamation,  should  receive  inunctions  or  baths  in  an  antiseptic  solu- 
lution  to  prevent  dissemination  of  the  exfoliated  epidermis.  The  quarantine 
should  be  continued  for  from  6  to  8  weeks  after  the  onset  of  the  disease. 

A  careful  system  of  school  inspection  will  do  much  to  prevent  the  spread 
of  this  infection. 

The  treatment  of  the  disease  itself  consists  in  strict  confinement  to  bed 
during  the  febrile  period  and  for  a  week  or  ten  days  thereafter,  the  control  of 
symptoms  and  in  the  prevention  of  complications.  The  mild  types  of  the  dis- 
ease need  little  or  no  medication.  The  sick-room  should  be  light,  weU- venti- 
lated and  kept  at  a  uniform  temperature  of  from  65°  to  68°  F.  (18.5°  to  20°  C). 
The  itching  and  burning  caused  by  the  eruption  may  be  relieved  by  inunctions 
of  carbolized  vaseline,  5  percent,  ichthyol  ointment  in  lanolin,  or  5  percent, 
boric  acid  ointment  in  vaseHne.  Sponging  with  very  weak  (J  percent.)  phenol 
solution  as  well  as  dusting  with  talcum  powder  are  also  useful.  Inunctions 
of  colloidal  silver  (unguentum  Crede)  may  exert  an  effect  upon  the  septic 
nature  of  the  disease  as  well  as  a  beneficent  influence  upon  the  skin.  Inunc- 
tions are  particularly  indicated  during  desquamation  to  prevent  the  dissem- 
ination of  the  scales.  Baths  of  warm  soapsuds  may  also  be  given  and,  if 
the  skin  is  irritated,  bran  baths  may  be  employed. 

The  temperature  in  ordinary  instances  may  be  neglected  but  should  it  rise 
above  104°  F.  (40°  C.)  it  may  be  reduced  by  the  application  of  an  ice  coil 
over  the  heart,  cool  sponging  or  cool  packs.  Quinine  has  been  advocated; 
the  only  effect  wliich  it  can  have  in  this  disease  is  to  temporarily  lower  the 
temperature.  For  the  cerebral  symptoms  cool  sponging,  the  ice  cap  and 
small  doses  of  salipyrine,  salophen,  acetphenetidine  or  antipyrine  may  be  em- 
ployed.    These  drugs,  while  reducing  the  tendency  to  insomnia  and  restless- 


SCARLATINA.  237 

ness,  also  have  an  antipyretic  effect.  A  daily  sponge  bath  with  tepid  water 
and  soap  should  be  given  for  the  sake  of  comfort  and  cleanliness. 

Stimulation  in  the  milder  forms  of  the  infection  is  unnecessary  but  in  severe 
instances  of  septic  or  anginose  type  with  weak,  rapid  and  irregular  pulse 
it  is  indicated.  Brandy  or  whiskey  is  usually  preferable,  the  dose  depending 
upon  the  condition  in  hand.  Digitalis  in  the  form  of  the  tincture  may  be 
given  when  the  pulse  is  rapid  and  of  low  tension,  the  dosage  for  a  child  5  or  6 
years  old  being  i  drop  (0.065)  every  5  or  6  hours.  Strychnine  in  doses  of 
from  Y¥T5"  to  xiir  of  ^  grain  (0.0003  to  0.0006)  may  be  given  alone  or  in  con- 
nection with  other  stimulants. 

Throughout  the  disease  the  bowels  should  be  kept  freely  open,  an  initial 
course  of  fractional  doses  of  calomel  followed  by  a  mild  saline  being  indicated 
at  the  onset.  As  the  disease  progresses  saline  laxatives  may  be  given  from 
time  to  time  or  the  high  intestinal  irrigation  with  hot  water  (112°  F. — 44.5°  C.) 
may  be  employed.  The  latter  is  a  most  excellent  stimulant  and  diuretic 
and  an  aid  of  considerable  value  in  the  elimination  of  the  poison  of  the 
infection. 

Pilocarpine  has  been  recommended  in  the  treatment  of  scarlatina;  it  is 
said  to  reduce  the  temperature,  to  improve  the  condition  of  the  throat  and  to 
prevent  glandular  involvement.  It  should  not  be  given  with  the  coal  tar 
antipyretics  and,  should  idiosyncrasy  to  the  drug  be  present,  atropine  will 
be  found  to  be  an  effective  antidote. 

The  simple  form  of  pharyngitis  needs  no  other  treatment  than  a  mild 
antiseptic  mouth  wash  or  throat  spray  of  Dobell's  solution  or  of  diluted  liquor 
antisepticus  which  should  be  applied  every  4  hours.  Nasal  involvement 
should  be  controlled  by  syringing  or  spraying  with  similar  agents.  The 
severer  throat  inflammations  should  be  carefully  treated  in  order  to  prevent, 
if  possible,  aural  complications.  Here  hot,  or  preferably  cold,  applications 
should  be  made  to  the  throat  externally  and  endeavors  should  be  made  to  keep 
the  throat  itself  as  nearly  clean  as  possible.  Frequent  irrigations  of  hot,  mildly 
antiseptic  solutions  such  as  ^  saturated  solution  of  boric  acid,  o.i  percent, 
iodine  trichloride,  0.2  percent,  salicylic  acid,  etc.,  are  useful.  The  irrigation 
should  be  of  considerable  quantity  and  given  while  the  child  is  lying  with  its 
head  turned  to  one  side  and  slightly  lower  than  the  res  of  the  body.  It  may 
be  given  by  means  of  a  fountain  or  ordinary  syringe  to  which  a  soft  rubber 
catheter  is  attached.  If  the  swelling  is  marked  and  there  is  tendency  to 
oedema,  sprays  containing  adrenalin  chloride  may  be  employed  and  steam 
inhalations  impregnated  with  compound  tincture  of  benzoin  or  eucalyptol 
may  be  prescribed.  Insufflations  of  equal  parts  of  sozoiodol  and  sublimed 
sulphur  are  recommended;  10  percent,  phenol  in  glycerin  may  by  injected 
into  the  seat  of  the  inflammation  in  instances  of  gangrenous  tonsillitis. 

Slight  enlargements  of  the  cervical  glands  usually  subside  without  treat- 


238  THE    INFECTIOUS    DISEASES. 

ment  but  more  marked  glandular  involvement  necessitates  the  employ- 
ment of  continuous  cold  by  means  of  the  ice  bag  held  in  place  by  bandages. 
Inunctions  of  ointment  of  colloidal  silver  (unguentum  Crede)  are  useful  and 
a  thin  gauze  compress  impregnated  with  10  percent,  ichthyol  ointment  may 
be  applied  to  the  glands  beneath  the  ice  bag.  The  presence  of  pus  demands 
immediate  incision  and  drainage. 

The  prevention  of  complications  is  a  most  important  part  of  the  treatment 
of  this  disease.  While  at  times  these  occur  in  spite  of  all  attempts  at  prophy- 
laxis, this  fact  should  not  deter  the  physician  from  employing  every  means 
in  his  power.  In  preventing  the  incidence  of  nephritis  it  is  particularly 
necessary  to  watch  the  urine  carefully,  examining  it  at  least  once  a  day,  to 
studiously  guard  the  patient  against  exposure  to  draughts,  to  continue  the  fluid 
diet  and  the  confinement  to  bed  for  at  least  a  week  after  all  febrile  symptoms 
have  disappeared  and  not  to  allow  the  patient  to  leave  the  sick-room  too  soon. 
It  is  far  better  to  err  upon  the  safe  side  in  this  regard  than  to  permit  the  patient 
to  go  out  too  early.  Recently  the  use  of  hexamethylene  (urotropin)  has 
been  advocated  as  a  prophylactic  against  scarlatinal  nephritis  and  has  seemed 
efficient  in  some  instances  while  inert  in  others;  it  certainly  can  do  no  harm 
when  given  in  proper  dosage  and  carefully  watched.  The  prophylactic  use 
of  digitalis  has  also  been  recommended  and  it  would  seem  that  the  employ- 
ment of  high  rectal  irrigations  of  hot  saline  solution  should  be  effective.  The 
treatment  of  scarlatinal  nephritis,  when  it  occurs,  is  identical  with  that  of 
acute  nephritis  when  occurring  from  other  causes. 

The  prevention  of  aural  complications  consists  in  the  methodical  and 
thorough  treatment  of  the  pharyngeal  conditions  as  laid  down  above.  The 
drum  membranes  should  be  inspected  daily  for  any  sign  ef  bulging  and,  when 
necessary,  immediate  paracentesis  should  be  done,  the  opening  to  be  kept 
free  as  long  as  there  is  the  slightest  tendency  to  discharge.  The  discharging 
ear  should  be  irrigated  with  warm  boric  acid  solution  in  considerable  quantity 
every  4  hours.  The  practitioner  should  never  hesitate  to  summon  the  otolo- 
gist in  consultation  when  the  condition  is  in  the  least  doubtful,  for  upon 
proper  management  of  the  aural  complications  of  scarlatina  the  patient's 
hearing  may  depend.  Mastoiditis,  internal  ear  involvement,  sinus  thrombosis, 
etc.,  are  conditions  for  the  otologist  alone  and  their  discussion  is  beyond  the 
scope  of  this  work. 

The  treatment  of  the  joint  complications  consists  in  immobilization  and 
the  application  of  hot  moist  compresses.  While  by  no  means  always  satis- 
factory in  its  results,  the  administration  of  the  salicylates  should  be  under- 
taken. These  may  be  given  in  appropriate  dosage  by  mouth,  or  salicylic 
acid  may  be  given  by  inunctions  as  suggested  under  the  treatment  of  acute 
articular  rheumatism.  Acetyl-salicylic  acid  (aspirin),  adult  dose  from  gr.  x 
to  XV — 0.66  to  1.0,  may  be  employed.     The  chronic  joint  complications  neces- 


FOURTH    DISEASE.  239 

sitate  the  internal  and  external  exhibition  of  the  preparations  of  iodine.  The 
presence  of  pus  in  a  joint  is  an  indication  for  immediate  surgical  inter- 
ference. 

The  treatment  of  the  other  complications  is  identical  with  that  to  be  insti- 
tuted when  these  occur  independently. 

Advances  have  been  made  during  recent  years  in  the  serum  treatment  of 
scarlatina  by  means  of  antistreptococcus  serum;  this  serum  is  used  rather 
to  combat  the  complications  which  are  due  to  streptococcus  infection  than 
with  the  hope  of  influencing  the  disease  itself.  The  results,  particularly 
those  attained  with  Moser's  serum,  would  seem  to  justify  the  employment 
of  this  means  of  treatment.  It  is  particularly  indicated  in  the  severer  and 
complicated  types  of  the  infection.  The  serum  is  given  in  considerable 
amounts  and  acts  best  when  administered  in  the  early  stages.  The  initial 
dose  may  be  about  5  drachms  (20.0)  and  a  total  quantity  of  5^  ounces  (180.0) 
has  been  given.  The  disadvantages  of  the  treatment  are  its  costliness  and  the 
large  amount  of  serum  necessary. 

Von  Leyden's  so-called  convalescent-serum  is  reported  to  achieve  good 
results. 

The  treatment  of  convalescence  consists  in  the  employment  of  tonics  and 
careful  watching  of  the  urine  which  should  be  examined  at  intervals  for  a 
considerable  period.  Persistent  nasal  and  throat  symptoms  necessitate 
the  employment  of  antiseptic  sprays. 

The  diet  of  the  disease  should  be  wholly  of  milk — plain  or  peptonized — 
throughout  the  febrile  movement  and,  as  a  preventive  of  nephritis,  for  a  week 
or  ten  days  after  the  normal  temperature  has  been  reached.  After  this  time 
an  ordinary  regimen  may  be  gradually  and  carefully  resumed. 

FOURTH  DISEASE. 

Synonym.    Dukes's  Disease. 

This  affection  is  considered  by  Dukes  to  be  an  independent  disease  of  mild 
character  which  simulates  mild  scarlatina,  but  differs  from  it  in  that  its  incu- 
bation period  is  much  longer,  being  from  9  to  21  days,  and  in  its  lack  of  pro- 
dromal symptoms.  The  eruption  resembles  that  of  scarlet  fever  except 
that  it  appears  first  upon  the  face;  it  is  usually  followed  by  profuse  desqua- 
mation. 

Many  observers  doubt  the  existence  of  this  disease  as  a  separate  entity, 
and  it  is  certain  that,  before  its  identity  can  be  clearly  established,  further 
study  must  be  made  of  rubella.  It  has  been  suggested  that  this  affection 
may  be  the  result  of  a  simultaneous  infection  with  scarlatina  and  rubella. 

Its  treatment  is  entirely  symptomatic  and  to  be  based  upon  that  of  the 
other  infectious  exanthemata. 


240  THE    INFECTIOUS    DISEASES. 

VARICELLA. 

Synonym.     Chicken-pox. 

Definition.  An  acute  infectious  febrile  disease  of  mild  type  characterized 
by  a  vesicular  eruption  and  usually  seen  in  children. 

.Etiology.  The  disease  occurs  sporadically  but  from  time  to  time  epidem- 
ics are  observed.  It  is  essentially  a  disease  of  children  but  adults  who  are 
not  immune  through  an  attack  in  childhood  are  quite  likely  to  contract  the 
infection.  The  affection  is  met  in  all  climates  and  at  all  seasons  and,  while  its 
specific  cause  has  not  yet  been  isolated,  it  is  presumably  a  micro-organism, 
probably  a  protozoon.  The  contagium  is  found  in  the  contents  of  the  vesicles 
and  the  disease  may  be  reproduced  by  inoculation  with  this.  The  disease 
is  markedly  contagious  and  may  be  transmitted  by  direct  contact  and  possi- 
bly through  a  third  person. 

Symptoms.  The  incubation  period  is  from  lo  to  i6  days  and  the  eruption 
may  be  the  first  noticed  symptom.  In  other  instances  there  may  be  mild  pro- 
dromata  such  as  irritability,  malaise  and  slight  fever.  The  invasion  may  be 
marked  by  a  slight  chill  followed  by  a  rise  of  temperature  to  ioi°to  103°  F.  (38.5° 
to  39.5°  C),  vomiting,  headache  and  perhaps  general  pains.  The  eruption  ap- 
pears, without  other  symptoms  or  within  24  hours  of  the  invasion,  first  upon  the 
upper  part  of  the  trunk,  although  it  is  first  observed  upon  the  face;  often 
here  the  rash  is  usually  scanty  but  the  scalp  is  always  involved.  It  occurs 
first  in  the  form  of  small  reddish  points  which  quickly  become  rounded  rose- 
colored  macules.  These  become  successively  papules  and  vesicles  within 
a  few  hours.  These  last  vary  from  jV  to  ^  an  inch  in  diameter  and  later 
contain  turbid  fluid.  Usually  they  are  not  umbilicated  but  at  times  this 
manifestation  may  be  observed.  In  about  48  hours  from  their  original  appear- 
ance the  spots  have  become  pustules  which  upon  being  pricked  collapse 
entirely,  which  is  not  the  case  with  the  pustules  of  smallpox.  The  rash  lasts 
from  2  to  5  days  when  the  pustules  begin  to  dry,  a  brownish  crust  resulting, 
which  soon  falls  leaving  no  scar;  in  certain  instances  a  depression  is  left  which, 
however,  is  seldom  permanent.  Successive  crops  of  the  eruption  appear 
and  the  rash  may  be  seen  in  all  stages  at  the  same  time.  If  the  vesicles  are 
scratched  or  irritated  small  cicatrices  may  remain.  The  rash  is  also  seen 
upon  the  lining  of  the  mouth  and  pharynx  and  perhaps  on  that  of  the  larynx. 
A  scarlatiniform  blush  may  precede  its  appearance.  The  eruption  of  vari- 
cella is  always  discrete  and  in  mild  infections  there  may  be  not  more  than  10  to 
20  vesicles  upon  the  whole  body. 

The  temperature  falls  by  lysis  as  the  rash  fades  and,  as  this  occurs,  the  other 
symptoms,  if  any  have  been  present,  disappear.  The  disease  in  children 
previously  healthy  is  very  mild  but  may  be  more  severe  in  those  less  fortunate. 
In  the  latter,  complications,  such  as  nephritis  and  paralyses,  have  been  observed. 


VARICELLA.  241 

A  haemorrhagic  form  of  the  disease  with  extravasations  of  blood  into  the 
eruption  and  from  the  mucous  membranes  has  been  described  and  gangrene 
of  the  skin  about  the  pocks  and  of  the  scrotum  has  been  noted  in  strumous 
children.     Erysipelas  and  adenitis  are  possible  complications. 

The  diagnosis  is  not  difi&cuh.  The  lack  of  constitutional  symptoms,  the 
occurrence  of  the  eruption  in  all  stages  at  one  time,  the  absence  of  umbil- 
ication  of  the  vesicles  and  of  a  surrounding  areola  are  characteristic.  There 
is  no  shotty  feel  under  the  skin  as  in  smallpox.  In  infants  the  differential 
diagnosis  between  severe  types  of  variola  and  mild  cases  of  varioloid  may 
present  difficulties. 

The  prognosis  is  uniformly  good,  although  in  institutions  and  unsani- 
tary districts  the  disease  is  prone  to  assume  a  severe  type,  and  complica- 
tions may  occur  which  are  likely  to  render  the  recovery  of  the  patient  some- 
what uncertain.  Immunity  is  usually,  but  not  invariably,  conferred  by  an 
attack. 

Treatment.  Prophylaxis  consists  in  isolating  the  patient  if  the  disease 
occurs  in  institutions  or  other  places  where  many  children  are  gathered.  In 
private,  quarantine  may  not  be  necessary  unless  the  other  children  in  the 
family  are  unhealthy  or  delicate.  Quarantine,  when  instituted,  should  be 
continued  until  the  last  crust  has  fallen,  the  patient  may  then  be  released 
and  his  apartment  disinfected;  cleaning  and  thorough  airing  will  usually  be 
found  sufficient. 

The  treatment  of  this  disease  is  simple  and  consists  chiefly  in  relieving  the 
symptoms.  The  fever  is  seldom  of  a  height  to  cause  alarm  and  may  be  easily 
controlled,  if  necessary,  by  means  of  cool  sponge  baths.  The  headache  may 
be  alleviated  by  means  of  cold  compresses.  The  bowels  should  be  kept 
open  and  the  skin  and  kidneys  active.  Cooling  drinks  may  be  grateful  to 
the  patient.  If  the  eruption  upon  the  buccal  lining  is  painful  this  symptom 
may  be  relieved  by  rinsing  the  mouth  with  a  2  percent,  to  4  percent,  cocaine 
solution.  The  mouth  should  be  kept  clean  by  means  of  mild  antiseptic 
washes;  catarrhal  conditions  of  the  upper  air  passages  and  glandular  involve- 
ment, which  may  be  observed  in  strumous  children,  may  be  combated  by 
the  means  suggested  under  the  treatment  of  scarlatina.  The  itching  of  the 
skin  may  be,  to  some  extent,  prevented  by  a  wash  of  very  weak  phenol  solu- 
tion, by  applications  of  carbolized  vaseline,  10  percent,  boric  acid  ointment  in 
lanolin  or  vaseline  or  a  3  percent,  ichthyol  ointment.  To  prevent  scratching 
in  infants  it  may  be  necessary  to  tie  up  the  patient's  hands  in  cotton  wrapped 
about  with  gauze.  It  is  important  that  the  urine  should  be  examined  at 
intervals   during  and  succeeding  the   disease. 

It  is  best  to  keep  the  patient  in  bed  during  the  febrile  movement  and    the 
diet  should  consist  of  fluids.     Ordinary  diet  may  be  gradually  resumed  after 
the  temperature  has  reached  normal. 
16 


242  THE    INFECTIOUS    DISEASES. 

SMALLPOX. 

Synonym.     Variola. 

Definition.  An  acute  infectious  disease  characterized  by  an  eruption 
which  appears  first  in  the  form  of  macules,  which  become  successively  pap- 
ules, vesicles  and  pustules,  upon  the  last  of  which  crusts  form  which  finally 
fall  and  leave  permanent  cicatrices. 

-Etiology.  This  disease  has  existed  in  various  parts  of  the  earth  since  a 
very  remote  period.  It  invaded  England  in  the  13th  century  and  later  was 
brought  to  America.  Before  the  introduction  of  vaccination  it  was  a  com- 
mon and  very  fatal  disease,  epidemics  being  by  no  means  infrequent.  Small- 
pox is  very  contagious,  almost  all  unvaccinated  persons  who  are  exposed 
contracting  the  disease;  instances  of  natural  immunity  have,  however,  been 
observed.  A  single  attack  usually  confers  immunity,  but  instances  in  which  2 
to  3  undoubted  attacks  have  been  experienced  have  been  reported. 

The  disease  occurs  in  individuals  of  all  ages  and  is  especially  fatal  in  children. 
Pregnancy  predisposes  to  the  infection  and  infants  exhibiting  an  active  erup- 
tion or  the  pock  marks  have  been  born  of  mothers  who  have  contracted  the 
disease  during  this  period.  Such  instances  are  rare  and  a  child  born  while 
the  mother  is  suffering  from  the  infection  rarely  contracts  it  if  immediately 
vaccinated. 

Males  and  females  are  equally  susceptible  but  smallpox  is  more  virulent 
in  dark  skinned  races  and  is  rapidly  disseminated  and  very  fatal  amongst 
aboriginal  tribes. 

The  disease  is  contagious  throughout  its  whole  course  after  the  appearance 
of  the  eruption  and  a  few  moments  of  association  with  a  sufferer  are  a  suffi- 
ciently long  time  to  contract  the  infection.  The  contagium  may  be  carried 
to  great  distances  on  clothing,  in  bedding,  etc.,  and  the  pulverized  dry  crusts 
retain  their  infectivity  for  several  years.  The  contagium  exists  in  the  blood, 
secretions,  the  contents  of  the  vesicles  and  pustules,  in  the  dried  crusts  and 
probably  in  the  excretions.  Inoculation  from  the  blood,  the  contents  of  the 
vesicles  and  pustules  and  from  the  scabs  is  possible  but  the  chief  mode  of 
transmission  is  probably  by  means  of  the  pulverized  crusts  which  are  taken 
in  upon  the  inspired  air.  The  poison  of  the  disease  may  be  transmitted  by 
a  third  person  and  upon  the  air  to  an  unknown  distance. 

The  severest  type  of  the  disease  may  be  contracted  from  a  very  mild  instance. 

The  specific  cause  of  smallpox  is  probably  a  micro-organism  and  much 
research  has  been  conducted  in  the  hope  of  isolating  it.  A  bacterium  has 
been  found  both  in  the  contents  of  the  pustules  of  smallpox  and  in  the  lymph 
of  cow  pox  which  may  prove  to  be  the  cause  of  the  disease,  and  protozoa  have 
been  described  which  exist  in  the  epithelial  cells  of  the  cutaneous  lesions. 

Pathology.     In  addition  to  the  typical  eruption  and  its  various  modifica- 


SMALLPOX,  243 

tions  certain  other  morbid  changes  are  found.  The  pustule  has  its  origin 
in  the  rete  mucosum  just  beneath  the  cutis  vera.  The  pus  focus  is  surrounded 
by  a  reticulum  infiltrated  with  serum,  leucocytes  and  fibrin.  The  central 
area  of  necrosis  finally  dries  and  forms  a  crust  which  falls,  leaving  no  scar 
if  the  process  extends  no  deeper.  If  the  papillae  of  the  true  skin  are  involved 
in  the  necrotic  process  and  are  destroyed,  the  loss  of  tissue  results  in  a  perma- 
nent cicatrix. 

The  eruption  may  occur  upon  the  mucous  membranes  of  the  mouth,  phar- 
ynx and  oesophagus,  the  agminated  glands  of  the  intestine  may  be  swollen 
and  a  few  pustules  may  appear  in  the  rectum.  They  also  have  been  observed 
upon  the  conjunctiva  and  upon  the  mucous  membranes  of  the  nose  and 
larynx.  The  lesions,  when  occurring  in  the  trachea  and  bronchi,  take  the 
form  of  ulcerous  erosions  rather  than  true  pustules.  In  the  haemorrhagic 
type  of  the  disease  there  may  be  extravasations  of  blood  beneath  the  skin 
and  mucous  membranes  as  well  as  into  the  viscera,  muscles,  marrow  and 
other   tissues. 

Laryngeal  oedema,  perichondritis  and  chondritis,  bronchitis  and  pneu- 
monia may  be  observed  as  associated  lesions  and  myocardial  degeneration 
may  take  place.  Peri-  and  endocarditis  are  seldom  seen  but  splenic  enlarge- 
ment is  common  and  the  liver  and  kidneys  are  the  seat  of  an  acute  degener- 
ation (cloudy  swelling).  True  nephritis  is  rare  but  may  occur  during  con- 
valescence. 

In  the  hemorrhagic  t>'pe  of  smallpox  the  spleen  is  likely  to  be  hard  and 
dense  and  the  liver  of  similar  consistency  or  the  seat  of  fatty  degeneration. 
•  Symptoms.     The    disease    occurs    in    three    types: 

a.  Variola  vera  of  which  2  forms  are  described,  i.  Discrete.  2.  Con- 
fluent. 

h.  Variola  haemorrhagica  of  which  2  varieties  have  been  observed,  i. 
Purpura  variolosa  or  black  smallpox.  2.  Variola  haemorrhagica  pustulosa 
or  pustular  haemorrhagic  smallpox. 

c.  Varioloid  or  smallpox  as  modified  by  vaccination. 
,  a.  Variola  vera,  discrete  form.  The  period  of  incubation  is  from  7  to  15 
days,  usually  12.  During  this  period  there  are  rarely  any  prodromata,  but  at 
its  end  the  invasion  of  the  disease  occurs  suddenly  with  one  or  more  chills. 
In  children  a  convulsion  is  a  frequent  initial  symptom.  There  are  head- 
ache, backache,  (which  is  characteristically  intense)  and  general  pains  with 
nausea  and  vomiting  and  prostration.  The  temperature  rises  rapidly  to  103° 
to  104  °  F.  (39.4°  to  40°  C.)  on  the  first  day,  the  pulse  is  rapid  and  tense  and 
nervous  symptoms  may  be  manifested;  even  delirium  may  be  present  in 
severe  infections.  The  skin  is  usually  hot  and  dry  but  in  certain  instances 
marked  sweating  may  occur.  The  severity  of  the  initial  symptoms  is  no 
indication  of  the  type  of  the  disease. 


244 


THE    INFECTIOUS    DISEASES. 


About  the  2d  day  the  initial  rash  appears.  It  may  be  either  diffuse 
and  scarlatiniform  or  macular;  while  these  eruptions  may  be  general  they 
usually  occur  only  upon  the  lower  abdomen,  the  sides  of  the  chest,  in  the 
axillary  region  and  upon  the  inner  aspects  of  the  thighs.  Haemorrhagic 
petechiae  may  accompany  them.  The  scarlatinal  type  is  the  more  frequent. 
Initial  eruptions  are  by  no  means  the  rule,  since  they  appear  in  only  from 
10  to  16  percent,  of  patients. 

About  the  4th  day  the  characteristic  eruption  of  the  disease  appears,  first 
upon  the  forehead  along  the  hair  line  or  upon  the  ventral  surface  of  the  wrists, 
whence  it  spreads  downward  over  the  trunk  and  limbs  becoming  general 


Fig.  10.— Clinical  chart  of  smallpox  showing  fall  in  temperature  upon  the  appearance 
of  the  eruption  and  its  rise  upon  the  incidence  of  the  stage  of  pustulation. 


usually  within  24  hours.  At  first  it  is  in  the  form  of  round  pale,  reddish 
macules  which  later  become  darker  and  slightly  elevated.  By  the  second 
day  the  papules  have  become  firm  and  impart  a  feeling  to  the  examining 
finger  as  of  shot  under  the  skin.  By  the  5  th  or  6th  day  the  papules 
become  vesicles  containing  clear  or  slightly  turbid  serum  and  umbilication 
is  present  which  is  a  characteristic  of  the  eruption  of  smallpox;  by  the  8th 
.  day  the  vesicles  become  pustules,  the  umbilication  disappears  and  the 
skin  and  mucous  membranes  become  tense,  swollen,  inflamed  and  painful. 
After  the  rash  has  persisted  for  from  10  to  12  days  the  pustules  dry  and  crusts 
form  which  finally  fall  leaving  no  scars  unless  the  deeper  layers  of  the  skin 
have  been  affected.     In  the  latter  event  pit-hke  cicatrices  of  varying  size 


SMALLPOX.  245 

and  depth  persist.     The  rash  appears  upon  the  mucous  membranes  as  well 
as  upon  the  skin. 

In  true  smallpox  there  is  a  distinct  leucocytosis.  At  the  end  of  the  first  week 
a  count  will  reveal  an  increase  to  12,000  or  15,000,  later  this  may  fall  but 
at  the  end  of  the  second  week  there  is  a  second  augmentation. 

The  temperature,  upon  the  appearance  of  the  eruption,  falls,  sometimes 
nearly  to  normal,  but  when  the  fluid  in  the  vesicles  becomes  converted  into 
pus  the  fever  (secondary  fever)  recurs  and  with  it  the  usual  symptoms  which 
accompany  an  abnormally  high  temperature  appear.  Not  unusual  symptoms 
of  the  disease  are  sore  throat  and  hoarseness,  due  to  the  eruption  upon  the 
pharynx  and  larynx,  vomiting  and  diarrhoea.  Splenic  enlargement  is  frequent 
and  albuminuria  may  be  present.  As  the  rash  drys  and  the  crusts  fall  the 
temperature  drops  and  all  the  other  symptoms  abate.  The  disease  is  said  to 
possess  a  characteristic  odor. 

In  the  confluent  type  of  smallpox  the  pustules  are  so  closely  situated  that 
they  coalesce.  This  manifestation  is  particularly  likely  to  be  present  upon 
the  face.  In  marked  instances  of  this  type,  the  skin  of  the  face  and  limbs  is 
thoroughly  infiltrated  with  pus,  the  temperature  is  high  (105°  F —  40.5°  C, 
or  more)  and  cerebral  symptoms  as  well  as  other  signs  of  a  severe  infection 
are  observed.  Salivation  may  be  present  and  there  is  enlargement  of  the 
superficial  lymph  glands.  The  appearance  of  a  patient  affected  with  con- 
fluent variola  is  most  revolting.  In  the  marked  infections,  from  the  loth 
to  the  12th  day  the  patient  becomes  progressively  weaker,  the  cerebral 
symptoms  increase  in  severity  and  death  may  take  place.  In  patients  who 
recover  the  secondary  fever  is  prolonged,  depending  upon  the  extent  of  the 
pustulation,  lasting  from  3  to  4  weeks.  At  the  end  of  this  period  the  pus 
dries  and  the  crusts  form.  These,  after  adhering  for  a  considerably  longer 
period  than  those  of  discrete  variola,  fall. 

b.  Variola  hemorrhagica.  The  purpuric  form  of  haemorrhagic  smallpox  is 
characterized  by  the  early  appearance  of  a  hsemorrhagic  rash  and  of  haemor- 
rhages from  the  mucous  membranes.  The  condition  is  a  very  fatal  one  and 
the  patient  may  die  even  before  the  appearance  of  the  papules.  Hematuria 
is  common  and  hasmatemesis,  haemoptysis  and  corneal  and  intestinal  haemor- 
rhages may  occur.  The  skin  may  be  purplish  and  the  patient's  appearance 
is  most  horrible.  The  temperature  may  not  be  greatly  elevated,  but  the  pulse 
is  rapid  and  small,  while  the  respirations  are  accelerated  out  of  proportion 
to  the  height  of  the  temperature. 

In  variola  hcemorrhagica  pustulosa  the  haemorrhages  do  not  appear  until 
the  stage  of  vesiculation  or  of  pustulation  is  reached.  Then  there  are  extrava- 
sations of  blood  into  the  areolae  of  the  pocks  and  later  their  contents  becomes 
bloody.  Haemorrhages  from  the  mucous  mernbranes  also  occur.  While 
this  type  of  variola  is  very  fatal,  recoveries  sometimes  take  place. 


246  THE    INFECTIOUS    DISEASES. 

These  malignant  forms  of  the  disease  are  much  more  prone  to  occur  in  the 
unvaccinated. 

c.  Varioloid,  or  smallpox  modified  by  vaccination  or  a  previous  attack  from 
the  disease,  is  usually  much  milder  than  the  unmodified  disease,  although  the 
initial  pains  may  be  severe.  All  the  symptoms  are  less  marked  and  the  eruption 
is  less  diffuse.  Secondary  fever  is  slight  or  absent,  the  initial  fever  dropping 
and  the  symptoms  clearing  with  the  appearance  of  the  eruption  which  matures 
rapidly.  Permanent  cicatrices  are  uncommon.  This  form  of  the  infection, 
in  rare  instances,  may  be  severe  and  even  fatal.  There  is  usually  a  direct 
ratio  between  the  length  of  time  intervening  between  vaccination  and  the 
attack  and  the  severity  of  the  latter. 

Unusual  types  of  variola  sometimes  are  observed.  Variola  sine  variolis 
or  sine  eruptione  has  been  described  and  a  form  of  the  disease  known  as 
horn-wart  or  stone-pox,  in  which  the  papules  dry  before  the  vesicular  stage, 
has  been  noted.  Another  abortive  form  is  crystalline-pox  in  which  the 
vesicular  fluid  remains  permanently  serous. 

Complications.  Those  referable  to  the  respiratory  system  are  oedema 
of  the  glottis,  inflammations  of  the  laryngeal  cartilages,  pleurisy  and  broncho- 
or  lobar  pneumonia.  Vomiting,  diarrhoea — particularly  in  children — and 
parotitis  may  occur.  Circulatory  complications  are  rare;  myocarditis  with 
inflammation  of  the  coronary  vessels  has  been  observed,  but  pericarditis  and 
true  endocarditis  are  very  seldom  met,  although  during  the  attack  of  the 
disease  an  apical  systolic  murmur  may  be  heard.  Albuminuria  is  common 
but  true  nephritis  is  rare.     Orchitis  and  ovaritis  have  been  described. 

Cerebral  complications,  such  as  persistent  delirium  or  coma,  occur  during  the 
acuity  of  the  infection  and  post-febrile  insanity  and  neuritis  have  been  reported. 
Joint  inflammations  may  complicate  convalescence  and  skin  manifestations, 
such  as  painful  acne,  furunculosis  and  localized  gangrene,  are  among  the 
most  important  sequelae. 

Formerly  the  neglect  of  the  eyes  was  responsible  for  various  ophthalmic 
complications  but  attention  to  the  cleanliness  of  these  organs  has  now  ren- 
dered these  less  common.  Otitis  from  extension  of  the  pharyngeal  inflam- 
mation may  occur. 

The  diagnosis  is  simple  after  the  appearance  of  the  characteristic  eruption 
and  in  the  earlier  stages  the  severe  pain  in  the  back,  the  shot-like  feel  of  the 
undeveloped  eruption  and  its  appearance  upon  the  forehead  about  the  hair- 
line are  diagnostic  points. 

The  catarrhal  symptoms  of  measles  and  buccal  spots  are  absent  which 
aids  one  in  differentiating  the  measles-like  initial  rash,  and  the  scarlatinal  form 
of  initial  eruption  is  less  persistent  than  that  of  scarlet  fever.  In  chicken-pox 
the  rash  is  present  in  all  stages  at  the  same  time  and  is  very  rarely  umbilicated. 

The  differential  diagnosis  of  the  haemorrhagic  type  from  epidemic  cerebro- 


SMALLPOX.  247 

spinal  meningitis  offers  difficulties.     The  only  safe  method  is  to  isolate  all 
suspicious  patients  until  the  diagnosis  is  confirmed. 

The  prognosis  varies  in  different  epidemics  but  at  best  smallpox  is  a  disease 
to  be  dreaded,  particularly  in  children.  Haemorrhagic  forms  are  generally 
fatal.  Pregnant  women  are  likely  to  abort  and  frequently  die.  Pharyngeal, 
laryngeal  and  pulmonary  complications  render  the  infection  especially  serious. 

Prophylaxis.  The  most  strict  isolation  is  absolutely  imperative  and,  if 
possible,  the  patient  should  be  removed  to  a  hospital  for  contagious  diseases. 
The  room  selected  should  be  divested  of  all  carpets,  pictures  and  hangings, 
and  all  superfluous  furniture  should  be  removed.  Before  the  door  a  sheet 
kept  constantly  moistened  with  i  to  20  phenol  solution  should  be  suspended. 
Thorough  ventilation  is  an  absolute  necessity.  The  nurse  and  physician 
should  wear,  while  in  the  sick-room,  a  gown  covering  all  the  other  apparel 
and  a  cap  which  are  to  be  removed  upon  leaving  the  patient.  None  but  the 
attendants  should  be  allowed  to  visit  the  patient.  All  bed  linen  and  clothing 
should  be  immersed  in  i  to  1,000  mercury  bichloride  or  3  percent,  phenol 
solution  immediately  upon  removal  and  allowed  to  stand  at  least  two  hours 
before  being  sent  to  the  laundry.  AU  dressings,  crusts  from  the  eruption  and 
sweepings  must  be  immediately  burned  and  the  patient  should  be  supplied 
with  separate  utensils  and  dishes. 

After  death  the  body  should  be  sponged  with  strong  phenol  or  mercury 
bichloride  solution,  the  mouth,  nostrils  and  anus  having  been  plugged  with 
pledgets  of  cotton  moistened  with  either  of  these,  it  should  then  be  vn-apped 
in  a  sheet  saturated  with  a  disinfectant,  placed  in  a  metallic  or  air-tight 
coffin  and  buried  as  soon  as  possible.  The  disposal  of  such  bodies  by  crema- 
tion is  always  to  be  preferred  when  practicable. 

In  the  event  of  recovery  the  patient,  before  leaving  the  sick-room,  should 
receive  a  thorough  bath  and  shampoo  with  soap  and  hot  water  and  then  be 
sponged  off  with  a  i  to  3,000  solution  of  mercury  bichloride  or  immersed 
in  a  I  to  5,000  bichloride  solution  bath.  He  should  then  be  dressed  in  a  clean 
night  dress  and  removed  to  another  apartment  where  he  may  put  on  other 
clothing.  The  quarantine  should  be  insisted  upon  until  the  skin  is  clean 
and  smooth  and  no  trace  of  the  crusts  remains. 

Room  disinsection.  The  disinfection  of  the  sick-room  and  its  contents 
depends  upon  the  means  at  hand.  If  a  steam  disinfecting  plant  is  conven- 
iently situated  the  bed,  bedding  and  other  fabrics  should  be  made  into  bundles, 
wrapped  in  clean  sheets  and  removed  for  steam  disinfection.  By  care  in 
transportation  such  packages  may  be  transferred  with  little  danger.  The 
bedstead,  furniture  and  wood  work  must  be  carefully  washed  with  a  soft 
cloth  wet  with  i  to  1,000  mercury  bichloride  or  3  percent,  solution  of  phenol. 
All  cracks  and  crevices  should  receive  studious  attention.  The  removal  of 
superfluous  objects  greatly  simplifies  the  disinfecting  process.     The  walls, 


248  THE    INFECTIOUS    DISEASES. 

if  painted,  should  be  treated  in  the  same  manner  as  the  wood  work;  if  papered 
they  should  be  thoroughly  rubbed  with  pieces  of  bread,  then,  if  practicable, 
the  old  paper  should  be  removed  and  burned  and  the  walls  re-papered.  After 
attention  to  these  details  all  the  windows  and  the  doors,  with  one  exception, 
should  be  closed  and  sealed  by  pasting  strips  of  paper  with  common  flour 
paste  over  all  the  cracks.  The  sealing  process  is  important,  for  upon  the 
tightness  of  the  room  depends,  in  great  measure,  the  efi&cacy  of  the  disinfection. 
If  the  cracks  allow  the  escape  of  the  disinfecting  gas,  the  process  is  of  little 
value.  Before  sealing  the  last  door  all  draperies  which  have  not  been  removed 
must  be  spread  out  and  all  drawers,  closet  doors,  etc.,  widely  opened. 

Sulphur  dioxide  or  formaldehyde  gas  may  be  used  to  disinfect  the  room. 
If  the  apartment  is  bare  and  contains  little  decoration  the  former  may  be 
employed;  if  the  reverse  is  the  case  the  latter  is  to  be  preferred.  If  sulpliur 
disinfection  is  chosen,  four  pounds  must  be  used  for  each  1,000  cubic  feet 
of  room  space.  A  simple  method  of  generating  the  gas  may  be  arranged  as 
follows:  Two  or  three  bricks  are  laid  upon  the  bottom  of  an  ordinary  wash 
tub  and  upon  these  is  placed  a  dish-pan  or  other  metal  receptacle  which  is  to 
hold  the  sulphur.  The  tub  should  contain  enough  water  to  cover  the  bricks 
and  the  bottom  of  the  pan,  so  that  there  shall  be  no  danger  of  fire.  For  this 
reason  the  vessel  which  holds  the  sulphur  must  never  be  placed  upon  the  floor. 
The  sulphur  is  to  be  broken  in  small  pieces,  over  which  alcohol  is  poured  and 
set  on  fire  by  touching  a  match  to  the  mixture.  The  operator  should  stand 
at  as  great  a  distance  as  possible  while  applying  the  match.  If  enough  alcohol 
is  used  the  sulphur  will  be  almost  entirely  consumed,  and  it  is  important  that 
the  pan  should  not  contain  too  much  sulphur,  as  in  this  case  the  combustion 
will  not  be  complete.  On  this  account  it  is  better  to  use  two  or  more  pans  for 
the  sulphur  if  the  room  is  large.  To  produce  proper  disinfection  it  is  nec- 
essary that  moisture  be  present,  and  to  provide  for  this,  unless  the  weather 
is  damp,  we  must  supply  this  lack.  This  may  be  done  by  boiling  water  over 
a  gas  stove  or  by  pouring  boiling  water  from  one  vessel  into  another  in  the 
room  just  before  the  disinfection  is  begun.  Another  method  is  to  place  a 
vessel  of  water  a  few  inches  above  the  burning  sulphur.  The  sulphur  should 
always  be  prepared  so  that  it  may  be  at  once  set  on  fire  after  the  moisture 
has  been  supplied.  After  lighting  the  sulphur  the  room  should  be  imme- 
diately closed  and  the  door  of  exit  sealed  as  described  above. 

If  formaldehyde  gas  is  employed  it  may  be  generated  from  tablets  in  a 
specially  designed  lamp  or  generated  from  formalin  in  an  apparatus  which 
sends  the  gas  rapidly  through  a  tube  passed  into  the  keyhole  of  a  door. 
The  latter  method  is  preferable  but  less  practicable  than  the  former. 

Whichever  method  is  chosen  the  room  should  remain  sealed  for  at  least  8 
hours.  Even  at  the  end  of  this  time  care  must  be  exercised  in  entering  the 
apartment  and  in  so  doing  one  should  wrap  the  face  in  a  wet  towel,  pass  quickly 


SMALLPOX.  249 

to  a  window  and  open  it,  allowing  the  gas  to  escape  and  the  fresh  air  to 
enter. 

Since  the  discovery  of  vaccination  by  Jenner  in  the  last  decade  of  the  i8th 
century  we  have  had  at  our  disposal  a  practically  absolute  preventive  of 
smallpox  and  since  that  time  the  disease  has  become  a  rarity  in  districts  in 
which  the  procedure  has  been  systematically  instituted.  Consequently  too 
great  insistence  cannot  be  laid  upon  the  necessity  for  the  routine  performance 
of  the  operation.  All  children  should  be  vaccinated  at  from  3  to  5  months 
of  age,  every  7  years  thereafter  and  in  the  intervals  whenever  smallpox  is 
prevalent;  one  should  never  be  satisfied  with  an  unsuccessful  attempt.  While 
vaccination  does  not  always  protect,  the  disease,  as  it  occurs  in  those  who  have 
undergone  the  operation,  is  very  rarely  severe. 

Treatment.  Since  no  means  exists  of  shortening  the  disease  when  once 
infection  has  taken  place,  the  treatment  is  to  be  directed  at  the  control  of  the 
symptoms  and  the  prevention  of  permanent  scarring.  At  the  onset  the  patient 
should  be  isolated  and  put  to  bed  in  an  airy  room,  the  temperature  of  which 
should  be  kept  constantly  at  about  65°  F.  (18.5°  C.)  and  the  bowels  should 
be  opened  by  repeated  fractional  doses  of  calomel  or  other  mild  laxative,  to  be 
followed  by  a  saline,  if  necessary.  The  symptoms  of  the  first  stage  which 
need  special  attention  are  the  pain,  the  vomiting,  the  diarrhoea  and  the  cerebral 
manifestations.  The  pain  may  be  relieved  by  the  administration  of  acetpheneti- 
dine,  acetanilide  or  salip}Tine,  usually  in  combination  with  caffeine  to  prevent 
heart  weakness.  Morphine  may  become  necessary  in  severe  instances.  The 
ice  cap  to  the  head  and  the  application  of  an  analgesic  liniment,  such  as  equal 
parts  of  menthol,  hvdrated  chloral  and  camphor,  may  prove  beneficial.  The 
vomiting  may  be  controlled  by  swallowing  small  pieces  of  cracked  ice,  by 
minute  doses  of  phenol,  hydrocyanic  acid  or  cocaine  or  by  frequent  sips  of 
iced  champagne,  and  the  diarrhoea  by  means  of  bismuth  naphtholate  or  iodo- 
phenolphthaleinate  (dose  of  either  gr.  v  to  viiss — 0.33  to  0.5);  bismuth 
subsalicylate  or  subgallate  in  connection  with  small  doses  of  opium  may  also 
be  employed  to  relieve  this  condition.  The  nervous  symptoms  may  be 
rendered  less  distressing  by  potassium  or  sodium  bromide  or  hydrated  chloral, 
any  of  which  may  be  given  per  rectum  as  well  as  by  mouth.  Sulphonmethane 
is  also  useful  and  in  the  extreme  instances  the  employment  of  morphine 
or  opium  in  small  doses  may  be  necessary. 

Cool  sponging,  tepid  tub  baths  and  the  ice  helmet  are  also  useful  in  the 
treatment  of  the  cerebral  manifestations. 

The  temperature  is  seldom  high  enough  to  cause  alarm  but,  if  necessary, 
it  may  be  reduced  by  the  application  of  the  ice  coil  over  the  precordium  or 
by  cool  sponging.  Rarely  is  cardiac  weakness  an  early  symptom  but  should 
this  be  the  case  stimulants,  such  as  caffeine,  alcohol  or  strychnine,  may  be 
given  hypodermatically. 


250  THE    INFECTIOUS    DISEASES. 

The  dryness  of  the  mouth  will  be  alleviated  and  the  activity  of  the  skin  and 
kidneys  will  be  favored  by  frequent  cold  drinks  which  should  be  offered  at 
intervals. 

The  eruptive  period.  During  this  stage  the  problem  confronting  us  con- 
sists of  two  parts,  the  treatment  of  the  cutaneous  manifestations  and  that 
of  the  constitutional  condition.  In  the  former  the  chief  object  is  to  prevent 
permanent  scarring  and  numerous  methods  have  been  employed  with  this 
end  in  view.  Of  these  the  simplest  and  one  of  the  most  efficacious  is  to  cover 
the  skin  with  a  thin  gauze  compress  which  is  kept  moist  with  cold  i  to  5,000 
to  10,000  mercury  bichloride  or  i  to  200  or  300  phenol  solution  and  is 
covered  with  oil-silk.  For  the  face  a  suitable  mask  can  be  made.  The 
phenol  has  the  especial  advantage  of  neutralizing  the  unpleasant  odor 
of  the  disease.  The  wet  compresses  have  a  certain  analgesic  effect  and  are 
grateful  to  the  patient.  Chpping  of  the  hair  is  necessary  if  the  eruption 
involves  the  scalp  to  any  extent.  Of  other  means  of  -treating  the  skin  the 
employment  of  wet  dressings  of  weak  thymol  or  potassium  permanganate 
solutions  may  be  mentioned.  Many  more  drastic  applications  have  been 
advocated,  such  as  touching  the  eruptive  points  with  pure  phenol,  painting 
with  silver  nitrate  solution  or  \  strength  iodine  tincture  and  even  opening  the 
pustules  and  touching  them  with  stick  silver  nitrate,  but  none  of  these  is 
likely  to  yield  better  results  than  the  simple  cold  wet  compress. 

Dusting  powders  have  a  place  in  the  treatment  of  the  eruption  especially 
in  its  early  stages.  Of  these  boric  acid,  bismuth  subgallate,  talcum,  or  a 
mixture  of  phenol  i  part  and  lycopodium  powder  and  zinc  oxide  of  each  16 
parts  are  to  be  recommended.  Scrub  baths  given  daily  are  said  to  prevent 
pitting  since  they  hinder  the  formation  of  the  vesicles  and  pustules;  they 
are,  however,  a  drastic  measure.  Continuous  warm  baths  have  also  been 
advocated.  The  administration  of  xylol — 100  to  120  drops  (6.66  to  8.0) 
in  divided  doses  every  24  hours  is  said  to  diminish  the  mortality,  to  lessen 
the  characteristic  odor  of  the  disease  and  to  tend  to  arrest  the  suppurative 
stage,  thus  influencing  the  occurrence  of  pitting. 

The  variolous  manifestations  in  the  nose,  mouth  and  throat  require  the 
external  application  of  cold  and  moisture  and  attention  to  the  cleanliness  of 
the  nasal  and  buccal  cavities.  Antiseptic  sprays  and  mouth  washes  such  as 
Dobell's  solution  or  diluted  liquor  antisepticus  are  useful  here  and  astringent 
washes  such  as  dilute  solution  of  potassium  chlorate  or  iron  perchloride  may 
be  employed.  The  discomfort  attendant  upon  the  appearance  of  the  erup- 
tion in  the  mouth  may  be  alleviated  by  means  of  sucking  bits  of  ice  and  by 
emollient  and  demulcent  drinks  such  as  thin  oatmeal  gruel  and  teas  of 
arrow-root  or  marsh-mallow.  If  ulcers  appear  they  may  be  touched  with 
a  20  percent,  silver  vitellin  (argyrol)  solution.  Localized  collections  of  pus  in 
the  pharynx  or  tonsils  should  be  immediately  opened  and  drained. 


SMALLPOX.  251 

The  conjunctival  eruption  should  be  carefully  treated  by  means  of  contin- 
uous compresses  of  cold  boric  acid  solution  (^  saturated)  and  by  instillations 
of  a  few  drops  of  a  10  percent,  argyrol  or  of  a  i  to  500  methylthionine  hydro- 
chloride solution.  Silver  nitrate  solution  may  be  used  but  is  painful  and  no 
more  efl&cacious  than  the  silver  vitelHn.  If  the  eyelids  tend  to  become  gummed 
together  this  may  be  prevented  by  anointing  their  margins  with  vaseline, 
either  plain  or  containing  5  percent,  of  boric  acid. 

After  the  crusts  have  formed  the  patient  should  be  advised  to  let  them  fall 
spontaneously  for  if  they  are  removed  before  they  are  wholly  loosened  the 
pitting  is  apt  to  be  more  pronounced.  Children  should  be  prevented  from 
scratching  by  bandaging  their  hands  loosely  in  gauze.  The  itching  during 
the  period  of  crust  formation  may  be  relieved  by  means  of  the  dusting  powders 
suggested  upon  the  previous  page  or  by  warm  baths  to  which  bran  may  be 
added  and  the  scales  may  be  protected  from  irritation  by  means  of  light 
dressings  of  carbolized  vaseline  or  vaseline  containing  5  percent,  of  boric  acid. 
If  the  scabs  become  detached  for  any  reason  before  the  skin  beneath  has  wholly 
healed,  the  suppurating  surface  should  be  cleansed  with  a  mild  antiseptic 
solution  and  dressed,  until  the  skin  has  reformed,  with  borated  vaseline. 
Exuberant  granulation  tissue  should  be  touched  with  stick  silver  nitrate  and 
dressed  antiseptically. 

The  treatment  of  the  constitutional  condition  during  the  stage  of  pustula- 
tion  offers  several  problems.  The  strength  of  the  patient  must  be  maintained 
by  proper  and  sufficient  nourishment  and  the  pyaemic  condition  necessitates 
the  employment  of  measures  such  as  are  indicated  in  suppurative  states  due 
to  other  causes.  Here  alcohol  in  the  form  of  brandy  or  whiskey,  2  to  4  ounces 
(60.0  to  120.0),  and  infusum  cinchonae  in  large  doses  are  highly  recommended. 
The  former  may  be  given  either  diluted  with  water  or  in  the  form  of  a  milk 
punch  with  egg;  to  the  latter  a  few  drops  of  dilute  hydrochloric  acid  and 
spirit  of  nitrous  sether  may  be  added  with  advantage.  The  fever  seldom 
needs  especial  treatment  but  should  it  be  alarmingly  high  the  application  of 
an  ice  coil  to  the  precordium  will  usually  result  in  a  considerable  reduction. 
The  coal  tar  antipyretics  should  be  employed  with  great  caution  if  at  all.  The 
condition  of  the  heart  should  be  carefully  watched  and  should  stimulation 
be  required  in  addition  to  the  alcohol,  strychnine  and  caffeine  may  be  given 
in  appropriate  doses  and  should  there  be  evidence  of  collapse,  h}^odermatic 
injections  of  camphor  dissolved  in  olive  oil  or  aether  become  necessary.  Ner- 
vous symptoms  may  be  controlled  by  the  bromides  and  hydrated  chloral 
which  may  be  given  by  rectum  or  by  mouth  as  indicated.  The  dose  of  the 
latter  must  be  such  as  to  be  in  no  danger  of  causing  heart  weakness.  Tepid 
baths  are  also  useful  in  relieving  the  nervous  hyper-excitability. 

The  administration  of  antistreptococcus  serum  has  been  suggested  as  a  means 
of  combating  this  stage  of  the  disease  and  not  without  reason,  since  the  pres- 


252  THE    INrECTIOUS    DISEASES. 

ence  of  the  streptococcus  in  the  contents  of  the  pustules  is  common.  This 
procedure  is  especially  indicated  in  patients  with  grave  septic  symptoms;  15 
drachms  (60.0)  may  be  given  in  3  doses  24  hours  apart  or  in  profoundly  toxic 
instances  this  quantity  may  be  given  in  one  day.  Attempts  at  controlling 
haemorrhages  may  be  made  by  giving  ergot  hypodermatically  or  better  by  the 
internal  or  rectal  administration  of  calcium  chloride.  The  latter  exerts  a  dis- 
tinct influence  in  increasing  the  coagulability  of  the  blood  and  may  also  be 
given  in  haemorrhagic  forms  of  the  eruption.  Its  dose  is  20  grains  (1.33)  3 
times  a  day.    It  should  not  be  given  for  more  than  three  or  four  days  at  a  time. 

The  treatment  of  the  complications  is  little  different  from  that  of  similar 
conditions  occurring  independently.  (Edema  of  the  glottis  may  demand 
scarification,  intubation  or  tracheotomy.  Pneumonia  should  be  prevented 
by  careful  management  of  its  precursor,  bronchitis,  and  by  frequent  turning 
of  the  patient  upon  his  side  to  prevent  hypostatic  congestion  of  the  bases  of 
the  lungs.  Pharyngeal  suppuration  and  furunculosis  necessitate  appropriate 
surgical  treatment. 

The  treatment  of  smallpox  by  means  of  red  light  has  recently  been  advo- 
cated, especially  by  Finsen,  who  considered  the  omission  of  this  method  to  be 
little  less  than  criminal.  The  idea  is  not  new,  having  been  exploited  by  John 
of  Gaddesden  in  the  14th  century.  According  to  Finsen,  who  excluded  the 
ordinary  daylight  by  means  of  panes  of  red  glass,  daylight  and  particularly 
its  chemical  rays  have  an  injurious  effect  upon  the  course  of  the  disease  since 
the  suppuration  of  the  vesicles  is  brought  about  by  exposure  to  unchanged 
sunlight.  Upon  the  infection  per  se  the  light  seems  to  exert  no  action.  The 
avoidance  of  suppuration,  however,  is  most  important,  since  the  stage  of  pus 
formation  is  the  most  dangerous  epoch  in  the  disease  and  many  fatalities 
result  primarily  from  the  suppuration.  The  method  must  be  properly  and 
systematically  employed,  but,  if  pus  formation  has  already  taken  place  or  is 
about  to  begin,  the  red  light  will  not  abort  it.  Finsen  considered  that  in  ordi- 
nary epidemics  this  treatment  will  reduce  the  death  rate  by  one-half.  Many 
other  observers  have  used  the  light  treatment  with  good  results  while  still 
others  are  much  less  enthusiastic  in  its  advocation. 

Other  methods  of  treatment  have  been  recommended  with  enthusiasm, 
among  which  may  be  mentioned  that  by  means  of  intestinal  antiseptics  such 
as  the  phenolsulphonates,  phenyl  salicylate  (salol),  mercury  bichloride,  etc., 
and  that  of  Talamon  who  applies  a  spray  to  the  skin  composed  of  mercury 
bichloride  and  tartaric  acid,  of  each  15  grains  (i.o),  alcohol  (go  percent.) 
one  and  a  quarter  drachms  (5.0)  and  aether  to  an  ounce  and  a  half  (45.0). 
With  this  the  skin  is  sprayed  for  i  minute  3  or  4  times  a  day,  the  eyes  being 
protected.  The  surface  is  first  washed  with  soap  suds,  rinsed  with  boric  acid 
solution  and  dried  with  cotton.  The  treatment  is  begun  with  the  appearance 
of  the  rash,  and  after  spraying,  the  face  is  covered  with  50  percent,  mercury 


,  VACCINIA.  253 

bichloride  glycerite.  After  4  days  the  spray  is  used  less  often  and  after  a 
week  it  is  discontinued,  the  glycerite  dressing  being  continued.  The  same 
observer  has  recommended  in  the  confluent  type  of  the  disease  baths  of 
mercury  bichloride  solution  lasting  45  minutes  to  i  hour,  internal  stimulation 
being  employed  at  the  same  time. 

The  serum  treatment  of  smallpox  has  thus  far  given  no  results  which 
render  its  use  justifiable.  Further  advance  in  the  elaboration  of  an  efficient 
serum  therapy  may  be  made  in  the  future. 

The  convalescence  usually  necessitates  the  employment  of  tonics  and  of 
easily  digestible  and  nutritious  food. 

The  diet  of  smallpox  should  be  carefully  regulated.  During  the  initial 
fever  only  fluids  should  be  allowed  but  in  the  remission,  before  the  stage  of 
pustulation,  semi-solids  such  as  gruels,  soft-boiled  eggs,  meat  jellies,  etc.,  may 
be  given.  At  the  onset  of  the  stage  of  pustulation  the  patient  must  return  to 
fluids;  it  is  at  this  time  particularly  necessary  to  maintain  his  strength,  conse- 
quently the  diet  should  be  as  concentrated  and  nutritious  as  possible. 

VACCINIA. 

Synonyms.     Cow  Pox;  Vaccine  Disease. 

Definition.  An  infectious  disease  characterized  by  an  eruption  and  pro- 
duced in  man  by  inoculation  with  the  contents  of  the  vesicle  of  cow  pox. 
Individuals  who  have  been  successfully  inoculated  are,  with  a  very  few  excep- 
tions immune  from  smallpox,  and,  even  if  able  to  contract  the  disease,  such 
subjects  are  affected  with  its  mildest  form,  varioloid. " 

Wliether  vaccine  disease  is  a  separate  disease  or  is  the  variola  of  the  human 
being  as  manifested  in  the  cow  is  a  moot  point,  opposite  views  being  held 
by  different  observers;  one  point  is  certainly  evident,  however,  to  the  un- 
prejudiced, and  this  is  that,  could  vaccination  be  systematically  and  thoroughly 
carried  out,  smallpox  would  become  an  unknown  disease.  Unfortunately 
certain  fanatics  oppose  the  compulsory  performance  of  the  operation  and, 
until  these  experience  a  change  of  heart  and  compulsory  inoculation  is  in- 
stitituted,  instances  of  variola  will  be  seen  from  time  to  time  and,  where  a 
proper  soil  is  offered,  epidemics  will  occur. 

That  inoculation  with  cow  pox  was  a  sure  preventive  of  smallpox  was 
discovered  and  proven  by  Edward  Jenner,  of  Gloucestershire,  England,  in 
1796. 

While,  in  all  probability,  vaccine  lymph  contains  a  specific  micro-organism 
which  is  responsible  for  the  train  of  symptoms  which  follows  inoculation, 
no  such  body  has  yet  been  successfully  isolated  although  much  research  upon 
this  subject  has  been  carried  out.  Various  bacteria  and  amcjeboid  bodies 
have  been  found  in  the  lymph  but  none  of  these  has  been  proven  to  be  the 
essential  cause  of  the  disease,  vaccinia. 


254  THE    INFECTIOUS    DISEASES. 

In  inducing  vaccinia  in  the  human  being  and  rendering  him  subsequently 
immune  to  smallpox  infection  two  varieties  of  virus  are  employed,  the  human- 
ized and  the  calf  lymph.  The  former  is  the  pus  from  the  pustule  of  a  vacci- 
nated human  being,  the  latter  is  the  contents  of  the  pustule  of  the  cow  or 
calf.  The  latter  is  chiefly  used  at  present  and  is  preferable  since  the  human- 
ized virus  is  capable  of  transmitting  syphilis  to  the  inoculated  person  should 
the  individual  from  whom  the  virus  has  been  taken  be  unfortunate  enough 
to  be  infected  with  specific  disease.  While  the  possibility  of  the  transmission 
of  tuberculosis  in  the  same  way  has  been  considered  it  has  never  been  proven. 

The  operation  of  vaccination  is  performed  as  follows:  The  site  selected  is, 
in  the  case  of  boys,  the  outer  side  of  the  arm  at  the  junction  of  its  upper  and 
middle  thirds.  In  vaccinating  girls  in  the  upper  walks  of  life  it  is  preferable 
to  use  the  outer  side  of  the  calf.  The  skin  over  the  part  chosen  should  be 
sterilized  by  washing  with  soap  and  water,  alcohol  and  i  to  5,000  mercury 
bichloride  solution,  wiped  with  sterile  water  and  allowed  to  dry.  Then  with 
a  needle,  which  has  been  sterilized  by  heating  in  a  gas  flame,  a  surface  one- 
eighth  to  one-fourth  of  an  inch  in  diameter  is  lightly  scratched,  care  being 
taken  not  to  draw  blood,  but  merely  to  remove  the  upper  layers  of  the  integu- 
ment. A  slight  exudation  of  serum  will  follow  this  procedure  and  into  this 
the  vaccine  should  be  rubbed  for  several  moments.  The  surface  should  be 
allowed  to  dry  and  then  dressed  lightly  with  a  compress  of  sterile  gauze. 
The  various  shields  sold  to  cover  vaccination  wounds  should  not  be  used. 
Different  makers  supply  dried  vaccine  upon  quills  or  ivory  points,  which  may 
be  used  instead  of  the  needle  to  abrade  the  skin.  When  from  a  reputable 
firm  these  may  be  employed.  The  health  boards  of  certain  cities  furnish  calf 
lymph  put  up  in  glass  tubes  and  packed  with  a  needle,  a  bit  of  wood  and  full 
directions  for  the  performance  of  the  operation. 

The  symptoms  following  vaccination.  Shortly  after  the  inoculation  there 
is  a  slight  inflammatory  reaction  at  the  site  of  the  abrasion  which  lasts  but  a 
short  time.  If  the  procedure  is  successful  and  the  vaccination  takes,  after  a 
period  of  incubation,  occupying  usually  3  days,  a  small  red  papule  appears, 
by  the  5th  to  the  7th  day  this  becomes  an  umbilicated  vesicle  surrounded  by  a 
pink  areola  and  containing  a  viscid  transparent  fluid;  by  the  loth  day  the  areola 
is  more  marked  and  the  fluid  has  become  purulent.  The  skin  surrounding 
the  pustule  is  often  indurated  and  tender.  Now  the  inflammation  gradually 
subsides,  the  contents  of  the  pustule  begins  to  dry;  about  the  14th  day  a 
brownish  crust  forms  which  becomes  hard  and  dry  and  faUs  about  the  21st 
dav,  leaving  a  roundish  depressed  scar  which  is  red  at  first  but  finally  becomes 
whiter  than  the  surrounding  skin. 

In  many  instances  constitutional  symptoms  accompany  the  evolution  of 
the  vaccinal  pustule.  These  vary  from  slight  malaise  and  irritability  with 
rise  of  temperature  about  the  3d  day  to  marked  prostration  with  a  febrile 


VACCINIA.  ■        255 

movement  lasting  from  i  to  2  weeks;  with  this  there  are  headache,  gastric 
disturbances,  restlessness,  etc.  The  number  of  white  blood  cells  is  increased 
and  enlargement  and  tenderness  of  the  axillary  or  inguinal  glands,  depending 
upon  the  site  of  the  inoculation,  occur. 

The  duration  of  the  immunity  conferred  by  vaccination  varies  in  different 
individuals  but  it  is  best  to  re-vaccinate  every  7  years  and  at  other  times  when- 
ever epidemics  appear.  After  from  10  to  15  years  a  second  vaccination  is 
usually  successful  but  the  pustule  and  the  constitutional  phenomena  are  less 
characteristic.  Even  in  first  inoculations  the  typical  result  may  not  be  at- 
tained. In  such  instances  the  operation  should  be  performed  again  and 
repeated  if  necessary  until  success  crowns  the  effort. 

Generalized  vaccinia  is  rare  but  may  manifest  itself  as  a  pustular  rash  on 
different  parts  of  the  body,  appearing  on  the  eighth  to  the  tenth  day;  the 
pustules  are  most  abundant  upon  the  vaccinated  limb  and  may  continue  to 
appear  for  several  weeks.     The  disease  may  prove  fatal  in  children. 

Complications  of  vaccination.  Cellulitis  may  occur,  especially  in  debili- 
tated children  as  a  result  of  contamination  at  the  time  of  operation  or  sub- 
sequently and  may  necessitate  the  employment  of  radical  surgical  measures. 
Erysipelas  is  a  serious  complication  and  great  care  should  be  used  in  vaccina- 
ting if  the  disease  is  prevalent.  If  the  disease  exists  in  the  family  of  the 
subject  about  to  be  vaccinated  the  operation  should,  if  possible,  be  post- 
poned. During  the  evolution  of  the  pustule  various  skin  eruptions  may 
appear  and,  in  certain  instances,  dormant  diseases,  such  as  tuberculosis  and 
hereditary  syphilis,  have  manifested  themselves. 

The  occurrence  of  tetanus  as  a  compHcation  has  been  noted  in  a  number 
of  instances  most  of  which  were  inoculated  with  lymph  from  one  particular 
producer.  The  possibility  of  such  contamination  should  render  us  especially 
careful  to  use  lymph  from  reputable  sources  only. 

The  treatment  of  vaccinia  is  wholly  symptomatic.  Mild  instances  need  no 
treatment  whatever.  Those  in  which  the  constitutional  manifestations  are 
unusually  severe  should  be  kept  in  bed  and  on  a  fluid  diet  during  the  febrile 
movement.  The  bowels  should  be  kept  open  and  the  kidneys  and  skin 
active.  The  local  condition  and  the  glandular  swellings  should  be  treated 
in  accordance  with  proper  surgical  methods  and  for  the  complications  the 
means  ordinarily  applicable  should  be  employed. 


256  CONSTITUTIONAL    DISEASES. 


CHAPTER  II. 

CONSTITUTIONAL  DISEASES. 

GOUT. 

Synonym.     Podagra. 

Definition.  A  painful  constitutional  disease,  acute  or  chronic,  due  to  an 
abnormal  quantity  of  the  antecedents  of  uric  acid  in  the  blood,  resulting  in 
various  symptoms,  of  which  joint  inflammation  is  the  most  prominent  and 
characteristic,  together  with  the  deposition  of  urates  in  the  neighborhood 
of   the   articulation. 

To  Wallaston's  discovery  in  1779  that  the  deposits  at  and  around  the  joints 
were  composed  of  urates  we  date  our  knowledge  of  this  disease  and  its  pathol- 
ogy. 

Etiology.  In  many  individuals  there  is  an  hereditary  tendency  but  the 
disease  may  also  be  earned.  In  more  than  half  the  patients  a  family  history 
is  obtainable. 

The  disease  is  more  frequent  in  males  than  in  females  and  it  is  through  the 
male  line  that  the  hereditary  tendency  is  more  likely  to  be  transmitted.  Gout 
is  seldom  seen  in  young  subjects  and  usually  shows  itself  after  the  age  of  forty. 
The  stigmata,  however,  of  the  gouty  diathesis  may  be  detected  as  early  as 
puberty.  The  most  common  causes  of  acquired  gout  are  excessive  eating, 
particularly  of  meats,  and  intemperate  drinking,  combined  with  sedentary 
habits,  yet  these  factors  are  by  no  means  essential  to  its  occurrence.  It  is 
also  true  that  not  all  who  possess  the  hereditary  tendency  suffer  for  the  indis- 
cretions of  their  forbears,  for  proper  mode  of  living  may  act  as  a  preventive. 

Over-drinking  is  a  chief  factor  in  the  production  of  gout,  but  the  form  in 
which  the  alcohol  is  ingested  has  a  certain  influence  on  the  incidence  of  the 
disease.  Heavy  ales  and  beers,  such  as  those  brewed  in  England,  are  more 
likely  to  bring  on  gout  than  are  the  lighter  malt  liquors  produced  in  America 
and  Germany.  Whiskey  is  less  to  be  avoided  in  this  connection  than  heavy 
wines,  such  as  port.  It  is  probable  that  the  excessive  carbohydrate  content 
of  these  beverages  is  the  causative  factor  of  the  disorder,  resulting,  as  it  does, 
in  the  products  of  gastric  acid  fermentation,  which,  upon  absorption  render 
the  blood  less  alkaline  and  less  solvent  of  uric  acid. 

Lead  poisoning  may  excite  an  attack  of  gout,  possibly,  as  suggested  by 
Haig,  because  it  may  reduce  the  alkalinity  of  the  blood. 

Local  traumatism  to  a  joint,  or  even  pressure  from  footwear  may  bring  on 


GOUT.  •  257 

an  attack  in  the  injured  part.  The  reason  of  the  predisposition  of  the  disease 
to  attack  the  great  toe  joint  is  unknown. 

Pathogenesis.  With  regard  to  the  pathogeny  of  gout  there  is  much  differ- 
ence of  opinion,  but  most  authorities  unite  in  beheving  uric  acid  to  some  ex- 
tent a  causative  factor.  Whether  this  substance  causes  the  train  of  symptoms 
known  as  "gouty"  by  its  increased  production  in  the  body,  by  its  diminished 
excretion,  or  both,  is  not  certainly  known.  We  are  not  unanimous  in  thinking 
that  the  sodium  biurate  which  forms  the  tophus  is  the  cause  or  the  result  of 
the  pathologic  process,  but  Sir  William  Roberts'  theory  that  uric  acid 
normally  does  not  as  such  circulate  in  the  blood,  but  only  as  a  soluble  quad- 
riurate  of  some  base,  is  probably  correct.  In  normal  urine,  uric  acid  is  always 
present  in  the  form  of  sodium,  potassium  or  ammonium  quadriurate.  These 
are  unstable  salts  and  in  the  presence  of  the  normal  sodium  chloride  solution 
of  blood  or  lymph  become  converted  into  the  more  stable  and  less  soluble 
biurates.  In  health  the  quadriurates  are  too  soon  removed  to  become  converted. 
Evidently,  therefore,  in  gout,  something  delays  excretion  long  enough  for 
them  to  be  changed  into  biurates,  and  this  takes  place  in  those  tissues,  such 
as  the  synovial  fluid,  the  cartilage  and  the  fibrous  tissues,  which  contain  the 
greatest  proportion  of  sodium  salts.  The  tophi,  therefore,  occur  first  where 
there  is  plentiful  synovial  fluid,  then  in  the  cartilages,  then  in  the  fibrous 
tissues. 

If  we  consider  all  sorts  of  conditions,  presenting  more  or  less  resemblance 
to  gout,  as  phases  of  this  disease  we  have  a  sort  of  anchorage,  but  one  which 
permits  of  much  deviation.  If  we  examine  the  various  statements  made  as 
to  the  disease  we  may  find  the  following  fairly  representative.  "In  gout 
we  have  a  disease  which  may  give  rise  to  almost  any  symptom  or  affect  almost 
any  organ  or  function."  If  we  start  with  the  patient  the  following  has  been 
presented:  The  gouty  individual  is  one  whose  general  metabolism  is  unstable 
and  this  instability  may  be  present  in  one  or  more  of  the  great  physiologic 
systems  (digestive,  circulatory,  nervous,  etc.).  If  these  statements  represented 
the  actual  state  of  our  knowledge,  one  might  readily  assume  that  we  had 
abandoned  our  anchorage  and  were  adrift.  Recently,  Woods  Hutchinson 
has  offered  the  following  statement  as  a  solution  of  the  difficulties  which 
beset  us,  defining  gout  as  "  a  disturbance  of  health  associated  with  the  presence 
of  excessive  amounts  of  urates  in  the  urine."  The  merit  of  this  definition  lies 
in  its  presenting  a  material  point  from  which  we  may  start.  It  fails  to  state 
what  the  corpus  deliciti  is,  although  deductively  it  is  not  uric  acid.  It  fails 
because  it  does  not  embrace  within  its  limits  those  instances  of  undoubted 
goutiness  in  which  "the  presence  of  excessive  amounts  of  virates  in  the  urine" 
is  inconstant,  and  it  proves  too  much,  because  leucocythaemia  and  the  renal 
infarcts  of  the  newly-born  are  included  by  the  definition,  but  are  admittedly 
not  involved  in  the  question,  so  far  as  the  symptomatology  is  concerned. 
17 


258  CONSTITUTIONAL    DISEASES. 

However,  as  a  starting  point  this  statement  is  useful  and  an  effort  will  be  made 
to  find  a  working  hypothesis  upon  which  we  may  base  a  plan  for  relief  of 
symptoms  and  disabilities  consequent  upon  disturbed  metabolism. 

Uric  acid  for  over  a  century  has  at  once  been  the  base  and  capstone  of  all 
pathologic  theory  with  regard  to  gout.  At  present  we  are  in  better  position 
to  reach  a  practical  working  basis  for  therapeusis. 

1.  We  are  reasonably  certain  that  uric  acid,  as  such,  is  not  toxic.  This 
fact  is  now  almost  universally  conceded. 

2.  The  presence  of  a  uric  acid  sediment  in  the  urine  does  not  of  necessity 
indicate  a  gouty  tendency,  for  the  power  to  hold  uric  acid  in  solution  in  the 
urine  depends  largely  upon  the  amount  of  pigment  and  the  percentage  of 
salts  contained  in  that  excretion. 

3.  A  nitrogen-free  diet  does  not  cause  an  abolition  of  uric  acid  excretion. 
And  finally, 

4.  The  excretion  of  uric  and  phosphoric  acid  goes  on  hand  in  hand — at 
least  during  attacks.. 

Examining  these  propositions  seriatim  we  see  that,  while  uric  acid  per  se 
is  not  toxic,  it  is  quite  possible  that  earlier  and  less  oxidized  bodies  are  probably 
so.  Therefore  the  increased  excretion  of  uric  acid,  signifying  the  increased 
or  complete  oxydation  of  uric  acid  antecedents  and  their  elimination  as  uric 
acid,  should  be  accompanied  by  a  relief  of  symptoms  referable  to  the  presence 
of  these  antecedent  bodies  in  the  organism.  In  practice  this  is  found  to  be 
true. 

Next,  the  observation  of  coincidence  of  marked  symptoms  and  diminished 
uric  acid  excretion  with  periods  of  relief  and  increased  uric  acid  excretion 
points  out  that  delayed  or  imperfect  excretion  of  uric  acid  is  concomitant 
with  exaggerated  pathologic  conditions.  Since,  as  has  just  been  stated,  uric 
acid  is  not  in  itself  toxic,  its  forbears  must  be  responsible  for  the  symptoms. 

As  a  nitrogen-free  diet  is  not  followed  by  an  absence  of  uric  acid  from  the 
urine,  the  formation  of  uric  acid  in  the  body  from  substances  contained  therein 
must  be  conceded.  This  uric  acid  is  very  properly  termed  endogenous  uric 
acid  and  is  independent  of  the  character  of  the  food  ingested.  It  is  the  exoge- 
nous uric  acid,  the  amount  varying  with  the  food  and  modified  by  various 
factors  which  act  on  digestion  and  absorption,  when  the  patient  is  on  ordinary 
diet,  that  completes  the  other  portion  of  the  total  uric  acid  excretion. 

As  uric  and  phosphoric  acid  excretion  bear  a  fairly  constant  relation  to 
one  another,  the  clue  is  at  once  given  as  to  the  probable  source  of  endogenous 
uric  acid.  This  soxirce  is  the  cell  nuclei  and  the  products  of  their  destruction 
are  both  uric  and  phosphoric  acids  as  they  appear  in  the  urine.  Therefore 
the  breaking  up  of  these  nuclei  gives  rise  to  the  appearance  of  uric  acid  and 
the  xanthin  bases,  which,  as  a  group,  constituting  the  alloxur  bodies,  are 
termed  purins  because  they  all  contain  the  radical  C5  H4. 


GOUT.  259 

Since  the  phosphoric  goes  hand  in  hand  with  the  xiric  acid  excretion,  it 
would  be  as  logical  to  direct  therapeutic  attention  to  the  former  as  to  the 
latter.  So  far  as  the  endogenous  uric  acid  is  concerned  we  may  define  gout 
as  a  toxaemia  of  varying  causation,  accompanied  by  the  formation  of  an 
excess  of  urates,  this  excess  being  due  to  the  breaking  down  of  the  leucocytes 
and  fixed  cells  in  the  attempt  to  neutralize  the  poison. 

Now  as  to  exogenous  uric  acid;  obviously  this  comes  from  without  and 
constitutes  the  source  of  the  smaller  moiety  of  the  total  output  of  uric  acid. 
Here  the  ingestion  of  food,  either  purin  free  or  of  small  purin  content,  must 
be  considered.  Obviously,  were  the  attempt  made  to  regulate  the  diet  accord- 
ing to  the  amount  of  purin  nitrogen  found  in  food,  various  articles  of  food 
would  be  permitted  which  experience  has  shown  to  be  detrimental  to  the 
patient.  And  after  all,  the  patient  must  not  be  disregarded,  for  the  metabolic 
reactions  of  the  gouty  are  indubitably  abnormal.  From  this  it  is  clear  that 
an  attempt  to  regulate  the  output  of  exogenous  uric  acid  by  altering  the 
intake  of  purin  containing  substances  must  be  futile  when  we  consider  that 
there  are  factors  influencing  metabolism  in  the  gouty  which  are  important. 

Recently  there  has  been  a  tendency  on  the  part  of  some  observers  to  return 
to  the  mechanical  theory  of  gout.  This  theory  advances  the  idea  that  the 
urates  deposited  in  the  joints  and  the  ligamentous  structures  about  them  act 
as  foreign  bodies,  obstruct  the  lymph  vessels,  cause  irritation,  and  exert 
pressure  upon  the  articular  and  peri-articular  tissues  and  interfere  with  their 
nutrition,  thus  explaining  the  pain,  redness  and  swelling  and  accounting 
for  the  degenerative  manifestations  which  result  later.  Old  deposits  of  the 
biurates  are  not  of  necessity  painful  but  it  is  the  opinion  of  most  observers 
that  fresh  deposits  of  these  substances  are  always  accompanied  by  painful 
symptoms. 

Pathology.  While  there  are  few  organs  or  tissues  which  may  not  be  the 
subject  of  gouty  changes,  the  characteristic  manifestation  of  the  disease 
is  in  the  acutely  inflamed  great  toe,  the  swollen  and  reddened  appearance 
of  which  has  but  to  be  but  once  seen  to  be  always  remembered.  Less  usual 
is  a  Hke  condition  of  the  thumb. 

The  manifestations  of  chronic  gout  are  less  typical  and  may  be  difficult  of 
differentiation  from  those  of  chronic  rheumatism.  Deposits  of  the  urates, 
however,  are  pathognomonic  of  gout.  These  occur  with  greatest  frequency 
in  and  around  the  joints,  involving  the  cartilages,  ligaments,  tendons,  bursae 
and  last  of  all  the  skin  and  connective  tissue.  Often  we  find  the  tophi  about 
the  finger  joints  or  in  the  aural  cartilages.  Upon  microscopic  examination 
the  cartilages  are  seen  to  be  infiltrated  with  sodium  biurate  crystals.  The 
tophi  may  ulcerate  through  the  skin  of  the  knuckle  joints  and  they  are 
frequently  accompanied  by  a  tendency  of  the  fingers  to  be  drawn  to  the  ulnar 
side  and  of  the  toes  toward  the  outer  side  of  the  foot;  this  latter  being  a  late 


26o  CONSTITUTIONAL    DISEASES. 

manifestations  and  frequent,  as  well,  in  arthritis  deformans  and  a  result  of 
the  fact  that  the  abductor  muscles  are  more  powerful  than  their  antagonists. 
The  tophi  should  not  be  mistaken  for  Heberden's  nodes  which  are  of  different 
origin  and  occur  in  arthritis  deformans.  These  are,  however,  more  prom- 
inent and  painful  in  gouty  subjects.  Various  exostoses  and  enchondromata 
or  "lippings"  from  the  cartilage  covering  the  articular  extremities  of  the 
bones,  especially  of  those  of  the  fingers  and  toes,  may  be  observed  but  should 
not  be  confounded  with  true  tophi. 

The  kidney  of  gout  is  the  granular  or  cirrhotic  kidney  and  is  not  in  any 
respect  different  from  the  ordinary  kidney  of  so-called  chronic  interstitial 
nephritis. 

The  heart  is  often  the  seat  of  an  hypertrophy,  especially  of  the  left  ventricle, 
and  its  valves  may  show  deposits  of  urates  upon  their  edges.  The  arteries 
are  usually  sclerosed,  which  fact  is  due  to  the  toxic  influence  of  the  xanthin 
bases. 

Symptoms.  Patients  in  whom  attacks  of  gout  are  frequent,  often  are  able 
to  foretell  a  coming  attack,  learning  from  experience  that  certain  symptoms, 
which  differ  in  different  individuals,  are  premonitory;  headache,  neuralgic 
pains,  disordered  digestion,  cardiac  irregularity  or  palpitation,  a  tense  pulse, 
a  feeling  of  weariness,  depression,  etc.,  may  be  mentioned  in  this  connection. 

Any  circumstance  which  tends  to  lower  vitality,  or  intemperance  in  eating 
or  drinking,  may  bring  on  an  attack. 

Usually  the  first  symptom  noted  by  the  patient  is  a  pain  in  a  joint,  usually 
in  the  metatarso-phalangeal  articulation  of  the  great  toe.  Its  onset  is  sudden 
and  its  character  is  sharp  and  stabbing.  A  chill  may  usher  in  the  attack. 
Accompanying  the  pain  are  the  symptoms  of  local  inflammation;  heat,  red- 
ness, swelling  and  tenderness,  although  there  may  be  pain  without  these 
manifestations,  or  there  may  be  local  signs  with  discomfort.  The  attack 
usually  begins  at  night  and,  if  the  first,  it  may  not  be  typical  and  therefore 
remain  undiagnosticated.  As  morning  comes  on  the  pain  becomes  less, 
perhaps  to  recur  during  the  night  following,  and  for  from  four  days  to  a  week 
the  cycle  continues — worse  at  night,  better  during  the  day.  With  the  attack 
there  is  commonly  a  moderate  rise  of  temperature  (100°  to  102°  F. — 37.8° 
to  38.4°  C),  which  may  continue,  with  morning  remissions,  as  long  as  the 
acuity  of  the  symptoms  persists.  After  a  few  days  the  pain  and  other  symp- 
toms subside  and  the  skin  of  the  affected  part  desquamates. 

The  urine  during  the  attack  is  scanty,  high  in  color  and  specific  gravity, 
may  contain  a  little  albumin  and,  if  allowed  to  stand,  is  likely  to  show  a 
sediment  of  urates  and  uric  acid.  Glucose  also  may  be  present.  After  the 
attack  the  amount  of  uric  acid  excreted  through  the  urine  may  be  increased; 
before  its  onset  and  during  its  acuity  this  may  be  diminished. 

Gouty  pharyngitis  may  be  the  only  manifestation  of  an  acute  attack  and 


GOUT.  261 

is  impossible  of  diflferentiation  from  other  forms  of  sore  throat  which  show 
only  redness  and  slight  swelling. 

The  local  symptoms  of  an  attack  of  acute  gout  may  suddenly  disappear 
and  manifestations  due  to  derangement  of  the  internal  organs — notably  the 
stomach,  heart,  brain  or  bladder — may  as  suddenly  appear.  In  such  instances 
the  gout  is  described  as  " retrocedent "  or  "metastatic."  The  symptoms 
referable  to  the  heart  may  be  pain,  dyspnoea  or  urregularity  of  action;  those 
referable  to  the  stomach,  pain,  vomiting,  or  diarrhoea;  those  referable  to  the 
brain,  various  meningeal  disturbances;  and  those  referable  to  the  bladder, 
those  of  inflammations  of  that  organ  or  of  the  prostate  gland.  Skin  eruptions 
(eczemas)  have  been  described  in  this  connection. 

Atypical  Gout.  Certain  symptoms  not  distinctive  of  gout  may  appear  in 
persons  of  gouty  tendency  and  in  such  patients  are  of  undoubted  gouty  origin. 
These  include  almost  any  mentionable  symptom;  of  them  the  most  usual  are 
various  muscular  pains,  headaches,  digestive  disorders,  burning  and  tingling 
of  the  palms  and  soles,  digitis  mortui. 

Certain  changes,  not  characteristic,  occur  in  the  organ  of  vision  as  a  result 
of  the  disease — except  rarely,  in  patients  in  whom  there  are  deposits  of  the 
urates  in  various  tissues  of  the  eye. 

Chronic  Gout.  When  a  patient  has  continued  to  have  numerous  attacks  of 
gout  changes  take  place  in  his  tissues — as  described  in  the  section  on  pathology 
— such  as  the  deposits  about  the  joints  and  in  the  cartilages,  the  deformities  of 
the  extremities  and  the  morbid  degenerations  of  the  kidneys  and  blood-vessels. 

Treatment.  The  treatment  of  gout  resolves  it  into  the  management  of 
the  acute  attack  and  that  of  the  gouty  tendency 

a.  The  treatment  of  the  acute  attack.  When  the  attack  occurs  in  a  healthy 
person,  in  whom  there  exists  no  reason  for  limiting  our  efforts,  the  indication 
is  to  prescribe  the  drug  or  drugs  which  will  most  quickly  reUeve  the  patient 
of  his  misery.  Colchicum  will  relieve  the  pain  and  in  the  salicylates  we 
have  agents  which  will  hasten  the  elimination  of  the  purin  bodies  which  are 
the  caiisa  causans  of  the  attack.  The  following  capsule  is  recommended: 
I^,  colchicinse  saUcylatis  gr.  t^tt  (0.0006),  methylis  salicylatis  minims  vi 
(0.4) ;  make  one  capsule.     Signa — Take  one  every  hour  until  pain  is  relieved. 

When  the  acute  symptoms  have  abated  the  indication  is  to  relieve  the  system 
of  the  accumulated  purin  bodies  and  to  prevent  their  further  retention.  (See 
treatment  of  chronic  gout  and  purinaemia,  p.  263.) 

In  patients  who  have  suffered  frequent  and  repeated  attacks  of  gout  and 
whose  heart  and  arteries  are  the  seat  of  sclerotic  changes,  glyceryl  nitrate 
(nitroglycerine)  7^15— ?iT  gr.  (0.0006-0.0012)  and  strychnine  -jV  to  2T  gr. 
(0.002-0.003)  at  the  intervals  required  by  the  severity  of  the  degeneration, 
should  be  prescribed  to  dilate  the  arteries  and  to  counteract  the  depressant 
effect  of  the  colchicine. 


262  CONSTITUTIONAL    DISEASES. 

There  is  no  reason  why  an  attack  of  acute  gout  should  not  be  cut  short 
for  there  is  no  danger  of  the  disease  "  going  to  the  heart "  unless  we  fail  to 
open  the  arteries  and  to  provide  against  the  myocardial  degeneration. 

The  use  of  nucleinic  acid  in  the  treatment  of  the  uratic  deposits  has  been 
suggested  and  favorable  results  are  reported.  Nuclein  substances,  themselves, 
since  they  contain  abundant  purin  bases,  are  not  suitable  in  this  connection. 
Base-free  thymic  acid  has  been  used  in  attempting  to  lessen  the  size  of  the 
tophi,  which  seem  to  diminish  under  its  influence,  while  the  excretion  of  uric 
acid  is  increased. 

Quinic  acid,  particularly  quinic  acid  anhydride,  may  be  used  in  acute 
gout  in  doses  of  150  grains  (lo.o)  per  day.  It  is  reported  that  by  its  admin- 
istration the  pains  are  greatly  ameliorated  and  the  local  signs  about  the  joints 
are  lessened.     This  substance  regularly  diminishes  the  output  of  uric  acid. 

Certain  authorities  recommend  hypodermatic  injections  of  antipyrine 
in  the  neighborhood  of  the  affected  joint,  since  this  drug,  in  addition  to  its 
analgesic  effect,  is  said  to  have  a  specific  action  in  gout. 

The  wine  of  colchicum  seed,  in  beginning  dosage  of  one-half  drachm  (2.0)  in 
combination  with  potassium  iodide  or  sodium  salicylate,  is  frequently  used 
in  acute  as  well  as  in  chronic  gout,  the  dosage  of  the  two  latter  being  up  to 
one  drachm  (4.0)  a  day  in  divided  doses. 

For  the  pain  acetphenetidine  (phenacetine),  antipjTine  saHcylate  (sali- 
pyrine),  and  saligenin  tannate  have  their  advocates.  Hypodermatic  injec- 
tions of  morphine  will  always  relieve  but  these  should  not  be  given  unless 
absolutely  necessary. 

The  insomnia  may  be  controlled  by  the  bromides  or  hydrated  chloral. 

The  diet  during  the  attack  should  consist  entirely  of  milk  and  vichy,  equal 
parts.  Of  this  eight  ounces  (250.0)  should  be  given  every  two  to  four  hours. 
This  tends  to  act  as  a  diuretic  and  to  cause  the  colchicum  to  be  absorbed  into 
the  circulation  rather  than  to  be  excreted  through  the  intestine  without  accom- 
plishing the  effect  for  which  it  is  administered.  It  is  very  important  that 
the  patient  should  drink  copiously  of  water. 

Local  Treatment.  The  joint  should  be  protected  by  a  generous  swathing 
of  cotton,  and  various  local  applications,  warm  rather  than  cold,  may  be 
made,  always  remembering  that  it  is  very  important  that  the  skin  should 
be  kept  intact.  Painting  with  collodion,  (not  more  than  two  coats)  either 
with  or  without  the  tincture  of  iodine,  may  afford  relief  as  may  also  any  of  the 
following  applications:  Sodium  bicarbonate,  i  to  16  of  warm  water;  equal 
parts  of  guaiacol  and  glycerin;  one  part  of  the  extract  of  belladonna  to  eight 
of  glycerin;  oil  of  peppermint;  chloroform  and  olive  oil,  equal  parts;  bella- 
donna liniment  and  chloroform,  equal  parts.  Local  applications  are  likely 
to  afford  less  relief  than  in  rheumatism  and  are  less  effective  cold  than 
warm.     At  times  the  tenderness  is  so  marked  that  not  even  the  bed  clothing 


PURIN^MIA.  263 

can  be  borne  upon  the  afflicted  part;  in  sucli  instances  the  use  of  a  frame  to 
support  the  sheets  is  advisable. 

PURINiEMIA. 

Synonyms.  Lithaemia;  Uricacidsemia ;  Uricaemia;  American  Gout;  Gouti- 
ness. 

Definition.  A  disease  of  rather  indeterminate  nature  dependent  upon  the 
presence  in  the  blood  of  partially  oxydized  food  elements  more  especially  the 
biurates. 

Etiology.  The  condition  is  caused  by  intemperate  eating  and  the  abuse 
of  alcohol,  combined  with  too  little  exercise  and  a  sedentary  habit  of  life. 
The  accumulation  of  the  urates  is  rather  due  to  their  production  within  the 
body  as  a  result  of  faulty  metabolism  than  to  a  too  great  ingestion  of  sub- 
stances which  contain  these  bodies. 

Symptoms.  Various  indefinite  symptoms  characterize  this  disease.  One 
of  the  most  constant  is  digestive  disturbance  which  may  be  manifested  by 
intestinal  fermentation,  constipation,  etc.  Headache  is  frequent  and  may 
be  accompanied  by  dizziness,  ringing  in  the  ears,  insomnia,  numbness  and 
tingling  of  the  hands  and  feet,  neuralgias  and  indefinite  pains  in  various 
joints  and  muscles  of  the  body.  Neurasthenic  symptoms  are  common  as 
well  as  irritability  of  temper.  Dermatoses,  such  as  eczema,  psoriasis  and 
pruritus  ani,  are  often  observed.  Palpitation,  cough  and  loss  of  flesh  and 
strength  may  be  present.  The  urine  usually  contains  less  uric  acid  than 
normal,  and  there  is  frequently  an  excess  of  indican  due  to  the  digestive  de- 
rangement. There  may  be  traces  of  albumin  and  a  few  hyaline  casts.  Crys- 
tals of  calcium  oxalate  are  often  seen. 

Treatment.  The  keynote  of  treatment  lies  in  (i)  limiting  all  toxic  influ- 
ences and  formation  of  toxins,  particularly  in  the  alimentary  canal,  in  order  to 
minimize  the  retrograde  metamorphosis  of  the  body  nucleins;  (2)  preventing 
the  absorption  of  all  toxic  material;  and  (3)  promoting  the  elimination  of 
toxic  agents. 

Diet.  The  diet  should  consist  of  purin-free  foods  in  so  far  as  possible ;  these 
are,  milk,  eggs,  butter,  cheese,  white  bread,  rice,  sago  and  fruits.  Those  con- 
taining under  two-hundredths  percent,  of  purin  nitrogen  are  beer,  stout,  onions, 
asparagus,  brown  bread.  Under  three-hundredths  percent,  oatmeal,  lentils, 
beans,  peas.  Under  five-hundredths  percent,  salmon,  cod,  pike,  halibut,  mut- 
ton, veal,  pork,  ham,  turkey,  chicken.  Under  one  percent,  liver,  steaks,  soups. 
Under  four  percent,  sweetbreads.  Obviously  were  the  attempt  made  to  regu- 
late the  diet  according  to  the  amount  of  purin  nitrogen  found  in  food,  various 
articles  would  be  permitted  which  would  prove  detrimental;  also  the  patient 
must  not  be  disregarded,  for  the  metabolic  reactions  in  this  gouty  condition 


264  CONSTITUTIONAL    DISEASES. 

are  indubitably  abnormal.  Hence  it  is  clear  that  any  attempt  to  regulate  the 
output  of  uric  acid  formed  in  the  body  by  altering  the  intake  of  purin-con- 
taining  substances  must  be  futile  when  we  consider  that  there  are  factors 
influencing  metabolism  in  our  patients  which  are  important.  Finally  the 
clinical  observation  that  the  appearance  of  an  excess  of  uric  acid  and  urates 
in  the  urine  is  generally  coincident  with  the  diminution  or  disappearance  of 
the  symptoms  leads  to  the  conclusion  that  the  elimination  of  bodies  antece- 
dent to  uric  acid  by  agents  which  increase  the  luic  acid  output  as  uric  acid 
is  also  not  to  be  forgotten. 

In  considering  endogenous  vuic  acid,  unquestionably  methods  whereby 
the  toxaemia  which  results  in  nuclear  destruction  is  obviated  should  be  con- 
sidered. Metabolism,  in  character  at  least,  is  profoundly  altered  by  the 
ingestion  of  various  substances  such  as  lead.  Waters  containing  lime  and 
iron  are  well  known  to  be  harmful.  Indirect  poisons  are  also  potent  as  well 
as  direct.  The  effect  of  alcohol  in  purina^mic  subjects  is  not  wholly  due  to  the 
alcohol  per  se,  but  more  probably  to  some  of  the  more  readily  fermentable 
carbohydrates,  as  the  cethers,  esters  or  acetone  groups  which  are  found  in  the 
sweeter  or  more  fruity  wines  used  by  the  rich,  or  accessory  products  found 
in  the  malted  beverages  drunk  by  those  in  moderate  circumstances.  The 
logical  inference  is  that  substances  capable  of  producing  intestinal  putre- 
faction, and  consequent  autointoxication,  should  be  prohibited. 

If  the  endogenous  uric  acid  is  restrained  as  to  its  amount  by  preventing 
unnecessary  waste  from  autointoxication,  exogenous  uric  acid  can  be  readily 
controlled.  Evidently  a  prohibition  of  red  meat,  as  has  been  the  custom, 
should  diminish  the  excretion  of  exogenous  uric  acid,  but  we  are  confronted 
by  the  fact  that  the  ingestion  of  nitrogen  is  essential  to  the  existence  of  the 
organism  and  so  far  we  cannot  make  use  of  that  contained  in  the  atmosphere. 
The  distinction  between  animal  and  vegetable  foods  is  more  apparent  than 
real,  for  the  glutens  (vegetable  albumins)  at  least,  are  assimilated  with  more 
difficulty  than  animal  albumins,  and  the  excess  of  carbohydrates  leads  to 
intestinal  fermentation  and  putrefaction.  Clinically  the  prohibition  of  red 
meat  has  not  been  a  success,  and  modern  research  tells  us  why  this  is  so. 
To  make  a  positive  statement,  it  can  be  safely  said  that  animal  food  in  moder- 
ation is  advisable.  Pickled,  salted  and  fried  meats  are  forbidden.  Fish  is 
excellent,  even  oysters  and  lobsters  are  permissible  if  fresh.  All  vegetables 
and  raw  fruit,  if  apart  from  meals,  are  allowable.  Tea,  coffee  and  cocoa 
in  moderation  are  permitted.  Alcohol  in  excess  and  inferior  wines  are 
injurious.  Malt  beverages  should  be  supplanted  by  cider,  in  quantity  not 
exceeding  a  pint  (250.0)  each  day.  As  has  been  pointed  out,  the  quantity, 
rather  than  the  variety  of  the  food,  is  to  be  limited.  All  rich,  highly-seasoned, 
greasy  and  twice-cooked  foods,  strong  soups,  cooked  tomatoes,  rhubarb,  sweet 
cooked  foods  are  to  be  avoided.     Large  mixed  meals  of  animal  and  farina- 


DIABETES    MELLITUS.  265 

ceous  foods  with  fruit  and  wine,  especially  if  the  latter  be  sweet  or  fruity, 
provoke  the  disease.  Plainly  cooked  animal  food,  preferably  roasted 
or  grilled,  and  limited  to  the  quantity  necessary  for  nutrition,  is  eminently 
satisfactory.  Two  ounces  (60.0)  per  day  of  good  whiskey,  well  diluted, 
will  satisfy  those  habituated  to  alcohol.  Excess  of  water  should  be  taken  only 
apart  from  meals.  Sedentary  habits  interfere  with  digestion  and  assimila- 
tion and  lead  to  the  ingestion  of  more  food  than  the  muscles  and  liver  can 
burn  up.  Consequently  an  out-of-door  life,  with  such  exercise  as  moderate 
bicycling,  golf  and  the  like,  is  to  be  recommended.  In  fact,  excessive  food, 
improper  forms  and  amounts  of  alcohol,  and  lack  of  exercise  are  factors  which 
lead  to  gout  and  the  purinaemic  conditions  which  are  earned  rather  than 
inherited.  The  last  therapeutic  fact  which  calls  for  comment  is  the  method 
by  which  an  excess  of  uric  acid,  and  especially  its  forbears,  is  remo  ed 
from  the  tissues.  The  alkalies  and  salicylates  are  our  chief  reliance  in 
that  they  not  only  make  these  products  more  soluble,  but  also  because  they 
favor  their  elimination.  The  prolonged  use  of  alkalies  is  obviously  disad- 
vantageous so  that  we  must  rely  chiefly  upon  the  salicylates.  One  of  the 
most  excellent  and  useful  of  the  forms  of  these  salts  is  saligenin  tannate, 
a  substance  obtained  from  several  species  of  Salix  and  Po pubis  (nat.  ord. 
Salicacem).  It  is  a  decomposition  product  of  the  glucoside  salicin  saligenin 
in  chemical  combination  with  castaneotannic  acid.  Over  salicylic  acid  it 
presents  the  advantage  that,  while  equally  efficacious,  it  does  not  disorder  the 
digestion  nor  cause  untoward  symptoms.  It  is  preferable  to  the  salicylates 
in  that  it  is  antiseptic,  while  the  latter  are  not,  and  it  easily  splits  up.  Over 
both  it  offers  the  advantage  of  larger  dose  and  longer  period  of  administration. 
The  dose  is  1 5  grains  ( i  .0)  in  powder  twice  or  three  times  daily  after  meals.  The 
bowels  should  be  kept  open  by  means  of  sodium  phosphate,  cascara,  podo- 
phyllin,  etc.,  as  in  all  conditions  where  free  elimination  is  necessary. 

Piperazine  water  will  be  found  useful  in  certain  patients  but  the  adminis- 
tration of  lithium  in  tablet  form  or  otherwise  is  Hkely  to  yield  little  or  no 
result;  the  bitter  tonics,  such  as  nux  vomica,  gentian  or  cinchona,  are  often 
useful.  The  headaches  and  other  pains  may  be  controlled  by  antipyrine 
salicylate  (salipyrine)  in  10  grain  (0.66)  doses  repeated.  Morphine  should  be 
used  only  as  a  last  resort. 

For  certain  patients  a  sea  voyage  or  change  of  climate  will  prove  of  benefit. 

DIABETES  MELLITUS. 

Synonyms.     Glycosuria;  Melituria. 

Definition.  Diabetes  mellitus  is  a  chronic  disease  characterized  by  an 
excessive  secretion  of  urine,  which  contains  glucose,  and  which  is  the  result 
of  a  disordered  metabolism. 


266  CONSTITUTIONAL    DISEASES. 

Etiology.  The  disease  is  more  common  in  males  than  in  females,  and  is 
most  frequently  seen  between  the  ages  of  30  and  60,  although  it  may  occur  in 
childhood  and  even  in  infancy.  Certain  races,  notably  the  Hebrew,  possibly 
because  this  is  an  essentially  dyspeptic  people,  are  more  prone  to  the  disease 
than  others.  Heredity  seems  to  influence  its  occurrence  and,  while  the 
disease  is  seen  more  often  in  the  well-to-do,  it  has  also  been  observed  in 
those  of  poor  circumstances.  It  is  a  rare  condition  but  seems  to  be  becoming 
more  common.  Its  definite  causation  is  very  obscure  but  it  is  in  essence  a 
disease  of  incomplete  oxidation  and  is  nearly  related  to  gout  and  purinaemia. 
The  fact  has  been  observed  that  diabetics  often  alternate  between  the  exces- 
sive elimination  of  urid  acic  and  of  sugar. 

Pathogenesis.  Notwithstanding  the  immense  amount  of  research  done 
in  connection  with  diabetes,  the  pathology  of  the  disease  remains  exceedingly 
obscure;  however,  we  may  consider  as  recognizable  three  classes  of  the  morbid 
condition. 

a.  The  pancreatic  form. 

h.  The  ahmentary  form. 

c.  The  nervous  form. 

Disease  of  the  pancreas  has  for  a  number  of  years  been  known  to  be  a 
factor  in  the  production  of  glycosuria.  Opie  has  demonstrated  that  partic- 
ular elements  in  the  pancreas,  namely,  the  islands  of  Langerhans,  must  be 
affected  to  produce  this  symptom.  The  most  frequent  pathological  change 
in  these  elements  which  results  in  the  appearance  of  sugar  in  the  urine  is  a 
sclerosis  or  degeneration  of  other  form,  hyaline,  for  instance.  The  glycosuria 
appearing  in  instances  of  cysts  of  the  pancreas,  cancer,  etc.,  is  probably  the 
result  of  a  temporary  involvement  -of  these  so-called  islands.  Also  the 
frequent  association  of  arteriosclerosis  and  diabetes  renders  it  probable  that 
this  condition,  by  its  interference  with  the  nutrition  of  the  pancreas,  may 
result  in  changes  which  lead  to  diabetes. 

Alimentary  diabetes  is  brought  about  by  some  disorder  of  the  digestive 
system  producing  an  interference  with  proper  carbohydrate  metabolism, 
which  results  in  an  hyperglycsemia,  which  is  due  to  the  presence  in  the 
organism  of  an  amount  of  glucose  with  which  the  body  is  unable  to  cope. 
For  instance,  in  certain  infectious  diseases,  exophthalmic  goitre,  alcoholism 
and  lesions  of  the  liver,  the  presence  of  an  amount  of  sugar,  of  which  the 
normal  organism  might  easily  dispose,  in  these  conditions  may  result  in  gly- 
cosuria, due  possibly,  as  pertinently  suggested  by  Pearce,  to  a  temporary 
interference  with  the  function  of  the  pancreas  due  to  circulatory  or  toxic  dis- 
turbances of  the  islands  of  Langerhans. 

The  nervous  type  of  diabetes  occurs  in  various  diseases  of  the  central 
nervous  system;  tumors,  and  other  lesions  of  the  floor  of  the  fourth  ventricle; 
traumatic  and  other  neuroses,  acromegaly,  etc. 


DIABETES    MELLITUS.  267 

Unfortunately  the  facts  known  to  us  concerning  this  disease  are  few  but  a 
summing  up  of  our  knowledge  would  seem  to  show,  according  to  Edsall,  that 
in  the  pancreas  resides  an  important  influence  over  carbohydrate  metabolism. 
How  this  organ  acts  is  not  known  but  it  is  not  merely  through  the  production 
of  a  glycolytic  ferment.  It  is  also  apparent  that  carbohydrate  metabolism 
is  associated  not  only  with  the  pancreas  but  with  other  organs,  notably  the 
liver,  as  well,  and  that  the  more  deeply  the  subject  is  studied  the  more  complex 
does  it  become. 

Pathology.  The  only  definite  pathology,  so  far  as  is  at  present  known,  is 
shown  as  a  sclerosis  or  degeneration  of  the  islands  of  Langerhans  in  the 
pancreas.  Also  this  organ  may  be  atrophied,  the  seat  of  an  interstitial  inflam- 
mation, of  malignant  growths,  or  cystic. 

The  liver  is  often  congested,  cirrhotic  or  the  seat  of  fatty  or  amyloid  degen- 
eration. 

The  kidneys,  while  they  primarily  have  no  influence  over  the  disease,  are 
frequently  found  in  a  state  of  hyperaemia,  catarrhal  inflammation,  or,  more 
rarely,  may  be  in  a  state  of  interstitial  inflammation. 

The  lungs  may  present  advanced  tuberculous  changes  or  may  be  the  seat 
of  a  pneumonia. 

The-  heart  is  often  affected  with  an  interstitial  myocarditis,  fibrous  or  fatty. 

The  brain  may  be  congested  or  oedematous,  the  seat  of  small  haemorrhages 
or  softened.  Tumors  of  the  pons,  the  medulla,  or  the  cerebellum  have  been 
observed. 

Symptoms.  Often  the  first  symptom  noticed  by  the  patient  is  an  excessive 
passage  of  urine,  the  characteristic  urine  of  a  diabetic  being  light  in  color, 
sweetish  in  odor  and  taste,  and  of  high  specific  gravity.  It  contains  glucose 
in  varying  quantity  and  perhaps  albumin.  The  urea  and  uric  acid  are  often 
increased.     Cramps  in  the  legs  may  be  obsen^ed  (Unschald's  sign). 

Excessive  thirst,  due  to  the  increased  elimination  of  fluids  through  the 
kidneys,  and  an  abnormaUy  large  appetite  are  frequent  symptoms. 

Itching  of  the  skin,  especially  about  the  vulva  in  women,  and  the  prepuce 
in  men,  where  this  symptom  is  due  to  the  irritation  of  frequent  urination,  is 
common  and  likely  to  result  in  eczema. 

The  breath  may  have  a  sweetish  odor  and  symptoms  of  indigestion  are 
common;  vomiting  may  occur.  The  bowels  are  usually  constipated,  but 
diarrhoea  may  be  present. 

There  is  often  emaciation  and  the  patient  complains  of  bodily  weakness. 

The  lungs  frequently  are  the  seat  of  a  chronic  bronchitis  and  complicating 
pulmonary  tuberculosis  is  common,  due  to  the  fact  that  the  powers  of  resistance 
of  the  organism  to  the  tubercle  bacillus  are  lessened  by  the  disease  and  the 
restriction  of  the  diet,  rather  than  to  any  direct  influence  of  the  diabetes  itself. 

Outbreaks  of  boils  and  carbuncles  are  not  rare;  the  former  may  occur 


268  CONSTITUTIONAL   DISEASES. 

early  in  the  disease  but  the  latter  seldom  appear  until  the  later  stages.  It 
should  be  remembered  that  during  the  course  of  a  carbuncle  in  a  non-diabetic 
patient  glycosuria  may  be  temporarily  present. 

Diabetic  gangrene  is  a  symptom  not  infrequently  met.  It  begins  in  the 
extremities,  usually  the  toes,  and  while  it  may  appear  spontaneously  from 
chronic  proliferative  endarteritis,  is  usually  the  result  of  traumatism,  often 
one  of  very  slight  character.  The  gangrene  is  usually  of  the  dry  or  senile 
type,  though  moist  gangrene  has  been  observed. 

Coma  is  a  serious  symptom;  usually  it  appears  in  the  later  stages  and  often 
results  in  death.  Its  onset  may  be  sudden  or  gradual.  If  the  latter,  the 
prodromata  are  dizziness  and  irritability,  the  patient's  condition  becomes 
more  and  more  stuporous  and  finally  ends  in  profound  coma.  Convulsions 
and  delirium  are  rare.  While  many  theories  have  been  advanced  as  to  the 
causation  of  the  coma  the  most  probable  one  is  that  it  is  due  to  an  acid  intoxi- 
cation, the  result  of  the  continued  presence  of  oxybutyric  acid  in  the  organism. 

The  blood  contains  glucose  and  the  red  cells  and  haemoglobin  are  likely 
to  be  diminished. 

Other  body  fluids,  such  as  the  saliva  and  perspiration,  contain  sugar  and 
this  has  also  been  found  in  the  transudates  and  exudates  in  diabetic  patients. 

Peripheral  neuritis  has  been  described  as  a  concomitant  of  diabetes. 

Abnormalities  of  the  eyes  occur,  such  as  cataract,  retinal  haemorrhages, 
choroiditis,  dilatation  of  the  retinal  vessles,  retinal  atrophy  and  retinitis. 

The  prognosis  varies  with  the  type  of  the  disease,  with  the  age  of  the  patient 
and  with  the  length  of  time  which  the  affection  has  existed  without  proper 
treatment.  Patients  in  whom  the  disease  begins  in  early  adult  life  are  seldom 
cured.  The  chances  of  recovery  for  the  patient  inclined  to  stoutness  and  in 
whom  the  disease  appears  in  middle  life  or  later  are  much  better.  The  form 
of  diabetes  resulting  from  disease  of  the  central  nervous  system  and  that  due 
to  permanent  sclerotic  changes  in  the  islands  of  Langerhans  are  hopeless  as 
regards  cure  but  not  as  regards  improvement.  The  alimentary  type  of  the 
disease  is  most  amenable  to  treatment.  While  we  may  consider  as  cured  the 
patient  who  no  longer  excretes  sugar  in  his  urine,  such  a  one  must  most  care- 
fully guard  against  a  recurrence. 

Treatment.  In  this  the  first  step  is  to  ascertain  with  which  type  of  diabetes 
we  have  to  deal;  consequently  we  prescribe  an  absolute  proteid  diet  in  connec- 
tion with  the  drinking  of  plenty  of  the  alkaline  waters  for  five  days,  for  diag- 
nostic purposes.  After  this  period  of  time  the  patient  is  required  to  present  for 
examination  two  specimens  of  urine,  one  the  first  passed  in  the  morning,  the 
other  the  last  voided  before  retiring  at  night.  If  the  sugar  content  is  as  when 
first  examined  it  is  probable  that  we  have  a  diabetes  due  to  nervous  lesion. 
Such  patients  are  however,  to  some  extent  amenable  to  dietetic  and  hygienic 
treatment.     If  we  find  a  smaller  amount  of  glucose  in  the  morning  specimen 


DIABETES    MELLITUS.  2-69 

than  in  that  passed  at  night  the  diabetes  is  of  the  pancreatic  variety.  If  we 
find  no  sugar  in  the  morning  urine  while  the  evening  specimen  shows  a  positive 
sugar  reaction  an  alimentary  diabetes  confronts  us. 

In  each  of  these  three  types  of  patients  treatment  may  be  considered  as 
being  a,  medicinal;  &,  dietetic;  c,  hygienic. 

Medicinal  Treatment.  The  drugs  to  be  preferred  are  those  which  act 
chemically  by  retarding  the  formation  of  glycogen  into  glucose.  Of  these 
the  author  prefers  uranium  nitrate,  which  may  be  administered  in  doses  of 
J  of  a  grain  (0.016)  three  times  daily  and  increased  gradually  up  to  a  maxi- 
mum of  from  3  to  4  grains  (0.20  to  0.25)  per  day. 

Jambul  acts  in  the  same  fashion  by  delaying  carbohydrate  conversion 
and  thus  enabling  the  organism  to  complete  the  process,  and  may  be  given, 
in  powdered  form,  5  to  30  grains  (0.33  to  2.00)  per  day  and  gradually  increased. 
As  much  as  an  ounce  may  be  administered  during  24  hours.  This  drug  is 
said  to  act  well  in  some  instances  and  not  in  others  and  considerable  difficulty 
may  be  experienced  in  selecting  proper  patients. 

Arsenic  is  another  remedy,  the  action  of  which  is  the  same  as  that  of  the 
two  preceding,  but  which  has  the  disadvantage  that  its  prolonged  administration 
is  likely  to  produce  digestive  disturbances,  neuritis,  herpes  zoster  and  fatty 
liver;  it  may  be  given  Fowler's  solution,  2  to  3  drops  (0.12  to  0.20)3  times 
Clemens'  solution  (3  to  5  drops — 0.20-0.33 — 3  times  a  day). 

Opium  has  enjoyed  extended  use  in  diabetes  and  seems  to  have  the  power 
to  diminish  the  excretion  of  glucose.  Its  great  disadvantages  are  the  proba- 
bility of  engendering  the  habit  and  the  constipation  attendant  upon  its  con- 
tinued administration.  The  employment  of  codeine  obviates  these  difficulties 
and  this  drug  may  be  given  in  doses  of  J  to  ^  a  grain  (0.016  to  0.032)  3  times 
a  day,  gradually  increased.  Given  in  connection  with  uranium  nitrate  its 
good  effect  may  be  augmented. 

Lithium  salts  act  by  assisting  oxidation  and,  in  combination  with  the  sali- 
cylates, are  useful  in  gouty  patients. 

Aceto-salicylic  acid  (aspirin)  in  mild  forms  of  diabetes  has,  according 
to  Williamson,  good  effects.  It  should  be  given  in  acid  solution — for  instance 
in  lemon  juice — to  prevent  digestive  disturbances — in  doses  of  5  grains  (0.33) 
4  to  6  times  a  day 

Calcium  phosphate  and  carbonate  have  lately  been  employed  with  good 
results,  perhaps  due  to  the  affinity  of  sugar  for  calcium. 

Potassium  iodide  has  achieved  results  in  glycosuria  due  to  cerebral  gum- 
mata  and  should  also  serve  in  the  gouty  form  of  the  condition. 

Antipyrine,  acetphenetidine  (phenacetine)  and  other  coal  tar  derivatives 
may  lessen  the  excretion  of  sugar  in  the  nervous  type  of  the  condition  because 
of  the  control  which  they  exert  over  the  conversion  of  proteid  into  sugar. 
They  may  also  may  be  found  useful  in  other  varieties  of  diabetes.     They  may 


270  CONSTITUTIONAL    DISEASES. 

be  given  in  doses  of  10  to  15  grains  (0.66  to  i.oo)  three  times  a  day  in  com- 
bination with  sodium  bicarbonate  and  preferably  when  the  stomach  is 
empty. 

Potassium  or  sodium  bromide  may  be  given  with  good  results  in  the  diabetes 
of  neurasthenics  or  in  that  of  mental  disturbance. 

Lactic  acid  in  doses  of  75  to  150  grains  (5.0  to  lo.o)  daily,  dissolved  in  water, 
has  been  recommended  by  certain  Italian  physicians. 

Gold  and  sodium  chloride  and  ergot  have  their  advocates  but  are  not  in 
general  use. 

The  various  preparations  made  from  the  pancreas  of  animals  of  which  much 
was  expected  have  so  far  failed  to  find  any  place  in  the  treatment  of  diabetes, 
and  the  same  may  be  said  of  the  extract  of  the  supra-renal  body. 

In  concluding  the  discussion  of  drug  treatment  it  may  be  said  that  too 
much  medication  in  diabetes  mellitus  should  not  be  advised.  Drugs  should 
not  be  given  when  we  are  able  to  cause  the  disappearance  of  the  sugar  from 
the  urine  by  dietetic  and  hygienic  treatment. 

Dietetic  Treatment.  An  exclusive  diet  of  proteids  and  fats  is  not  advisable 
unless  absolutely  necessary,  for  it  has  been  proven  that  coma  is  more  likely 
to  occur  in  patients  who  are  getting  absolutely  no  carbohydrate  food.  When 
carbohydrate  food  is  allowed  a  diabetic  we  must  see  to  it  that  the  organism 
is  able  to  take  care  of  it  and  does  not  excrete  it  as  glucose.  In  this  connection 
regulation  of  the  amount  of  carbohydrate  intake  and  proper  exercise  will 
do  much.  For  instance,  in  an  obese  diabetic  of  the  alimentary  type  who  is 
accustomed  to  little  exercise,  we  may  at  first  cut  out  most  of  the  carbohydrate 
foods  until  the  glycosuria  has  disappeared  and  then  gradually  allow  a  return 
to  a  mixed  diet,  slowly  increasing  the  patient's  physical  exercise  the  while 
so  that  he  may  be  able  thus  to  convert  the  steadily  augmenting  intake  of 
starchy  food.  Thin  patients  of  this  type  we  can  hardly  deprive  of  carbohy- 
drates, since  they  need  a  certain  amount  of  this  class  of  food  to  keep  up  their 
nutrition,  otherwise  this  deteriorates  and  the  diet  consisting  of  fats  and  proteids 
alone  is  almost  certain  to  engender  a  cirrhosis  of  the  liver.  Consequently, 
the  thin  alimentary  diabetic  may  be  allowed  starchy  foods  in  certain  quantity 
and  we  should  be  content  if  we  reduce  the  quantity  of  sugar  in  his  urine  to 
0.5  percent. 

With  regard  to  the  articles  of  diet  which  diabetics  may  be  allowed  it  may  be 
said  that  such  food  stuffs  should  be  selected  as  contain:  a,  no  carbohydrate 
whatever;  b,  very  little  carbohydrate  or  carbohydrate  in  easily  assimilable 
form  which  may  be  converted  by  the  organism.  To  the  first  class  belong 
all  varieties  of  fresh  and  salt  meat,  liver  excepted,  clear  meat  soups,  poultry, 
fish,  shell-fish,  butter  and  eggs,  fats  and  oils,  and  cheese. 

As  belonging  to  the  second  class  may  be  mentioned  the  green  vegetables, 
such  as  cabbage,  cauliflower,  Brussels  sprouts,  string  beans,  onions,  cucumbers, 


DIABETES    MELLITUS.  271 

tomatoes,  lettuce,  escarole,  romaine,  chicory,  water-cress,  spinach,  dandelion, 
beet  tops,  asparagus,  all  nuts  except  chestnuts,  all  the  acid  fruits,  and  jellies 
(unsweetened)  prepared  from  meat  juices  and  gelatin. 

Many  of  these  substances  contain  a  considerable  quantity  of  sugar  but 
not  in  the  form  of  grape  sugar.  The  various  sugars  and  starches  which  they 
contain  are  more  easily  converted  than  glucose  and  consequently  are  taken 
care  of  by  the  organism.  Fortunately  milk  sugar  is  of  this  class  and  milk 
may  be  freely  given  to  diabetics.  Other  sugars  which  are  likely  to  prove 
more  rapidly  convertible  than  glucose  are  leevulose,  the  sugar  of  fruit  and 
inosite,  the  sugar  of  muscle. 

With  regard  to  bread  it  may  be  said  that  the  toast  of  wheat  bread  24  hours 
old  is  preferable  to  gluten  or  graham  breads.  Gluten  flour  may,  however, 
be  used,  to  make  bread  or  biscuit  for  diabetics,  but  it  is  necessary  to  obtain 
a  pure  gluten,  which  is  impossible  in  the  United  States.  Cakes  and  biscuit 
made  of  flour  of  the  soya  bean  are  admissible  and  are  said  to  be  palatable. 
When  stale  they  are  likely  to  be  rancid  since  the  flour  contains  an  oil.  Bread 
made  from  aleuronat  flour  is  highly  recommended. 

Butter  may  be  eaten  by  diabetic  patients  but  it  is  best  to  limit  its  quantity. 

Beverages.  Tea,  coffee  and  cocoa,  with  cream  or  milk  and  sweetened 
with  beet,  not  cane  sugar  are  aUowable.  Saccharin  may  also  be  used  as  a 
sweetening  but  not  in  greater  quantity  than  J  grain  (0.016)  to  the  cup.  Gly- 
cerin has  been  employed  in  this  connection  but  is  inferior  to  the  above  named 
substances. 

Malt  liquors,  cider  and  other  fermented  liquors  are  not  permissible  since 
they  all  contain  sugar  or  starch. 

Wines  which  contain  no  sugar  or  only  a  very  small  quantity,  such  as  Bur- 
gundies, Bordeaux,  Rhine  and  still  Moselle  wines  and  dry  sherry,  may  be 
allowed. 

Whiskey,  gin  and  brandy,  when  unsweetened,  may  be  given  if  necessary, 
Schreiber's   dietetic  wines,  which   contain   no  sugar,  are  largely  employed. 

The  drinking  of  considerable  quantities  of  water  between  meals  is  to  be 
encouraged.  Patients  who  dislike  ordinary  water  often  will  take  large  amounts 
of  mineral  waters  when  prescribed  by  a  physician.  For  such  it  is  wise  to 
suggest  a  water  containing  as  little  mineral  as  possible,  such  as  Highland 
Spring  water. 

The  Potato  Treatment.  Some  authorities  believe  that  a  diet  of  potatoes  may 
be  prescribed  to  advantage  for  almost  all  patients.  One  to  two  pounds  (500 
to  1000)  of  this  vegetable  may  be  eaten  daily  with  the  result  of  diminishing 
the  thirst  and  the  glycosuria  and  of  improving  the  general  condition.  If  a 
diet  containing  bread  is  resumed  the  symptoms  recur,  only  to  disappear  upon 
a  return  to  potatoes.  The  reduction  in  the  sugar  is  said  to  be  due  to  the 
incomplete  absorption  of  the  carbohydrate.     It  is  also  possible  that  the  good 


272  CONSTITUTIONAL    DISEASES. 

of  the  potato  diet  may  result  in  part  from  the  alkaline  salts  which  these  vege- 
tables contain. 

Codliver  oil  may  be  found  helpful,  especially  in  weak  and  emaciated  patients, 
and  may  be  regarded  as  a  food.  It  acts  well  given  in  connection  with  brandy 
or  whiskey. 

Hygienic  Treatment.  Exercise  within  proper  limits  is  a  valuable  factor 
in  the  treatment  of  diabetes,  for  sugar  is  burned  in  the  muscles  as  well  as  in 
other  parts  of  the  body.  Excessive  bodily  fatigue  must,  however,  be  avoided, 
since  it  results  in  the  overwhelming  of  the  system  with  oxybutyric  acid  which 
is  likely  to  be  followed  by  coma.  Patients  whose  bodily  strength  is  good 
should  be  instructed  to  use  a  pedometer  and  walk  a  certain  distance  each  day. 
With  proper  attention  to  the  attire  pedestrian  exercise  may  be  taken  almost 
every  day  in  the  year.  A  moderate  amount  of  gymnasium  exercise  may  be 
taken  and  such  games  as  golf  and  croquet  are  to  be  recommended.  The 
important  point  with  regard  to  exercise  is  to  take  care  lest  it  be  carried  to 
excess.  Even  light  exercise  may  be  impossible  for  the  advanced  and  ema- 
ciated patients. 

Massage  is  indicated  in  patients  unable  to  take  active  exercise  and  in  the 
more  vigorous  it  may  be  found  a  useful  adjunct  to  the  other  forms  of  treat- 
ment. It  is  said  that  under  systematic  massage,  the  quantity  of  urine  and 
its  sugar  content  may  be  diminished  and  the  glucose  may  even  be  caused 
to  disappear.  Of  course  regulation  of  the  diet  is  also  necessary  to  produce 
this  result. 

Diabetics  should  clothe  themselves  in  a  hygienic  manner  and  particular 
attention  should  be  paid  to  the  wearing  of  proper  undergarments  during  the 
colder  months.  Frequent  changes  may  be  necessary  since  the  skin  in  this 
condition  excretes  certain  irritating  substances  which  if  allowed  to  remain  in 
contact  with  it  may  induce  an  eczema.  Proper  foot  covering  in  wet  weather 
is  a  necessity. 

Decency  requires  the  taking  of  at  least  two  warm  cleansing  baths  per  week 
and  more  than  these  will  do  no  harm.  A  cool  or  tepid  sponge,  according  to 
the  temperament  of  the  patient,  may  be  taken  daily. 

Fresh  air  is  a  necessity  and  the  diabetic  should  spend  much  of  his  time 
out  of  doors  and  should  sleep,  warmly  covered,  if  necessary,  in  a  large,  airy 
chamber  with  the  window  open. 

The  various  water  cures  and  spa  treatments  of  diabetes  are  often  found 
to  be  valuable  but  their  good  effects  are  probably  due  to  the  change  of  air, 
scene  and  diet,  together  with  a  regulation  of  the  mode  of  life,  rather  than 
to  any  peculiar  virtue  of  the  waters.  Alkaline  waters  may  give  benefit  on 
account  of  their  purgative  properties. 

Coma.  When  coma  is  feared,  either  from  the  existence  of  cerebral  symp- 
toms, from  a  sudden  diminution  of  the  glycosuria  or  when  acetone  is  present 


DIABETES    INSIPIDUS.  273 

in  the  urine  large  doses  of  sodium  bicarbonate  (i  to  2  drachms — 4.0  to  8.0 — 
3  or  4  times  a  day)  should  be  given. 

Coma  itself  should  be  treated  by  the  infusion  of  2  quarts  (litres)  of  0.9 
percent,  sodium  chloride  solution  at  112°  F.  (44.5°  C.)  into  the  median  basihc 
vein.  If  instruments  are  not  at  hand  the  same  quantity  of  the  solution  may 
be  given  by  hypodermatoclysis  at  110°  F.  (43.3°  C.)  or  per  rectum  at  116° 
to  iiS°  F.  (46.7°  to  47-8°  C.). 

In  any  case  the  bowels  should  be  freely  evacuated  in  order  to  rid  the  body 
of  toxic  substances  in  so  far  as  is  possible  and  hypodermatic  stimulation  should 
be  administered  as  indicated. 

Surgery  in  diabetic  patients.  Surgical  operations  in  diabetics  are  dan- 
gerous and  often  of  unsuccessful  outcome  because  of  the  co-existing  endar- 
teritis proliferans.  However,  if  the  disease  is  of  mild  type  and  the  sugar  can, 
by  treatment,  be  caused  to  disappear,  operations  of  necessity,  such  as,  for 
instance,  amputations,  may  be  performed,  but  with  a  guarded  prognosis. 

DIABETES  INSIPIDUS. 

Definition.  A  chronic  condition  characterized  by  the  passage  of  large 
amounts  of  a  urine,  light  in  color  and  in  weight,  but  otherwise  normal.  The 
affection  has  been  considered  a  stigma  of  mental  degeneracy. 

iEtiology.  Congenital  and  hereditary  instances  of  the  disease  have  been 
observed.  It  affects  young  adults  most  frequently,  being  rare  after  middle 
life;  it  may  occur  in  infancy.  The  condition  is  seen  more  often  in  males 
than  in  females. 

Clinically  two  types  of  the  condition  may  be  described,  the  idiopathic 
and  the  symptomatic.  The  former  occurs  primarily  and  is  associated  with 
no  morbid  lesion;  it  may  be  met  in  poorly  nourished  children,  after  the  drink- 
ing of  excessive  amounts  of  cold  liquids,  after  an  alcohoUc  excess,  as  a  result 
of  fright  and  in  convalescent  states. 

The  symptomatic  type  usually  accompanies  cephalic  injuries  and  such 
nervous  lesions  as  cerebral  tumors  and  hemorrhages,  lesions  of  the  fourth  ven- 
tricle, syphiUtic  growths  of  brain  and  cord,  etc.  Diabetes  insipidus  may  also 
be  associated  with  abdominal  aneurysm,  tumor  and  tuberculosis. 

The  pathogenesis  of  this  condition  is  best  explained  upon  the  ground  that 
it  is  caused  by  a  chronic  renal  congestion  due  to  some  vaso-motor  disorder 
of  the  blood-vessels  of  the  kidneys  which  may  result  from  direct  irritation,  as 
in  lesions  of  the  abdomen,  from  central  disturbance,  as  in  cerebral  lesions, 
or  from  irritation  of  the  medulla  oblongata. 

Pathology.  There  are  no  constant  morbid  changes  found  in  this  disease. 
Often  the  nerve  lesions  are  impossible  of  discovery;  when  these  are  demon- 
strable they  are  usually  at  the  base  of  the  brain.     In  certain  instances  there 


274 


CONSTITUTIONAL    DISEASES. 


have  been  enlargement  and  congestion  of  the  kidneys  and  bladder;  the  ureters 
and  pelves  of  the  kidneys  may  be  dilated  and  hypertrophy  of  the  ganglia  and 
degeneration  of  the  cells  of  the  solar  plexus  have  been  noted. 

S5nnptoms.  The  onset  of  the  disease  is  usually  gradual;  more  rarely  it 
appears  suddenly  after  a  debauch  or  an  injury  to  the  head.  The  most  char- 
acteristic symptoms  are  the  excretion  of  greatly  increased  quantities  of  clear, 
light  colored  urine  of  a  specific  gravity  sometimes  as  low  as  i,ooo,  and  an 
excessive  thirst.  Associated  manifestations  vi^hich  are  not  constantly  present 
are  a  lessened  perspiration  and  a  consequent  dryness  of  the  skin,  diminished 
salivary  secretion  and  dryness  of  the  mouth.  The  appetite  is  usually  not 
abnormally  large,  as  a  rule,  but  occasionally  it  is  increased.  The  digestion 
is  sometimes  impaired  but  in  most  instances  the  general  health  remains  good. 
More  rarely,  and  particularly  when  the  cause  of  the  disease  is  an  organic  one, 
weakness  and  emaciation  are  observed.  There  may  be  pains  in  the  back, 
especially  at  the  beginning  of  the  affection,  which  extend  down  the  thighs; 
diarrhoea,  mental  weakness  and  disordered  sexual  function  may  be  noted 
and  a  subnormal  body  temperature  has  been  observed. 

The  urine  is  often  passed  in  extraordinary  quantity,  a  daily  excretion  of 
25  to  40  pints  (12  to  20  litres)  being  not  unusual  and  even  much  larger  amounts 
have  been  observed.  The  color  of  the  urine  is  light,  this  secretion  at  times 
being  as  clear  as  water,  its  acidity  is  low  and  its  specific  gravity  diminished  even 
to  1 ,000.  Glucose  and  albumin  are  seldom  found  and  then  only  in  traces ;  inosite 
may  be  occasionally  found.  The  solids  are  usually  not  diminished  in  total 
amount,  the  urea  may  be  increased  to  even  several  times  its  normal 
quantity. 

The  diagnosis  is  not  difl5cult  as  a  rule,  the  absence  of  glucose  in  the  urine 
and  its  low  specific  gravity  easily  separating  the  disease  from  diabetes  mellitus. 
In  hysterical  polyuria  the  condition  is  not  permanent  and  there  are  accom- 
panying hysterical  symptoms.  Chronic  nephritis  with  greatly  increased  urine 
may  be  differentiated  by  the  presence  of  albuminuria  and  casts,  the  presence 
of  cardiac  and  arterial  changes  and  the  absence  of  marked  thirst. 

The  prognosis  in  the  idiopathic  instances  is  favorable  as  to  the  continuance 
of  life  and  recovery  is  not  impossible;  many  patients  continue  to  suffer  from 
thirst  and  increased  secretion  of  urine  for  long  periods  without  impairment 
of  health.  In  the  secondary  type  of  the  disease  the  prognosis  depends 
upon  that  of  the  cerebral,  abdominal  or  other  causative  lesion.  Patients 
suffering  from  this  form  of  the  affection  often  rapidly  become  weak  and 
emaciated. 

Treatment.  In  the  instances  due  to  nervous  or  abdominal  disease  the 
treatment  should  be  directed  at  these  conditions;  these,  however,  are  difficult 
of  cure  unless  syphilitic  in  nature  when  they  often  disappear  under  the  admin- 
istration of  mercury  and  the  iodides. 


DIABETES    INSIPIDUS.  275 

The  distressing  thirst  may  be  relieved  by  allowing  the  patient  to  hold  bits 
of  ice  in  the  mouth  and  the  employment  of  acidulated  drinks  such  as  lemonade. 
It  is  probable  that  the  patient  will  do  no  harm  by  drinking  sufficient  water 
and  other  innocuous  fluid  to  keep  the  thirst  in  check.  The  diet  should  be 
full  and  nourishing  and  the  general  health  should  be  maintained  by  advising 
warm  clothing,  moderate  exercise  in  the  fresh  air,  warm  baths  or  cold  douches, 
depending  upon  the  reaction  obtained,  massage  and  avoidance  of  exposure. 
Baths  and  frictions  also  aid  in  relieving  the  lessened  secretion  of  perspiration 
and  the  dryness  of  the  skin.  Counter-irritation  at  the  nape  of  the  neck 
or  over  the  epigastrium,  in  subjects  in  whom  the  condition  is  the  result  of 
nervous  or  abdominal  disease,  is  often  useful,  blisters  or  the  actual  cautery 
may  be  used,  and  in  spinal  lesions  especially,  the  galvanic  current  has  been 
warmly  recommended.  The  current  should  be  of  good  strength,  one 
pole  being  placed  over  the  neck  or  lumbar  region  and  the  other  over  the 
epigastrium. 

Numerous  drugs  have  been  employed  in  diabetes  insipidus.  Valerian  has 
the  recommendation  of  Trousseau,  and  should  be  given  in  large  doses;  the 
dose  of  the  powdered  root  being  about  30  grains  (2.0)  3  times  a  day;  the  fluid 
extract,  2  to  3  drachms  (8.0  to  12.0)  daily  in  divided  doses,  or  the  tincture  in 
drachm  (4.0)  doses  3  times  a  day  may  be  prescribed.  The  ammoniated 
tincture  may  be  substituted  if  desired.  Zinc  valerate  also  may  be  employed, 
given  in  pill  form  in  increasing  doses  until  15  to  20  grains  (i.o  to  1.33)  daily 
are  taken.  Ergot  in  doses  of  i  drachm  (4.0)  of  the  fluid  extract  3  times  a 
day  and  gradually  increased  to  double  that  amount  is  sometimes  effective 
as  is  also  antipyrine  in  daily  doses  of  from  30  to  45  grains  (2.0  to  3.0);  this 
latter  drug  should  be  used  with  caution  because  of  its  depressive  influence 
upon  the  heart.  Opium  has  been  recommended  but  there  is  always  the 
danger  of  habit  formation  to  be  considered.  It  may  be  prescribed  either 
alone  or  with  gallic  acid,  which  latter  has  proved  effectual  in  some  instances; 
10  grains  (0.66)  of  the  acid  to  J  of  a  grain  (0.022)  of  the  opium  may  be  given 
3  times  a  day.  Sodium  salicylate  has  its  advocates  and  favorable  results 
have  been  reported  from  the  hypodermatic  injection  of  strychnine  nitrate 
■^  to  Y2  of  2,  grain  (0.0025  to  0.005). 

Arsenic  sometimes  produces  good  results  and  its  use  in  connection  with 
the  bromides  is  suggested.  The  following  formula  is  an  excellent  one.  So- 
dium or  strontium  bromide  i  ounce  (30.0),  Fowler's  solution  of  potassium 
arsenite  2  drachms  (8.0),  iron  and  ammonium  citrate  2J  drachms  (lo.o)  cin- 
namon water  to  4  ounces  (120.0).  Of  this  one  teaspoonful  (4.0)  in  a  wine 
glass  (60.0)  of  water  is  to  be  taken  after  each  meal. 

In  addition  it  is  only  necessary  to  state  that  all  measures,  dietetic,  tonic, 
and  hygienic,  which  will  favorably  influence  the  patient's  general  condition 
are  valuable  adjuncts  in  the  treatment  of  this  disease. 


2  76  CONSTITUTIONAL    DISEASES. 


CHRONIC  RHEUMATISM. 


Definition.  A  chronic  inflammatory  process,  not  due  to  bacterial  infec- 
tion or  trauma,  affecting  the  softer  structures  of  the  joints. 

iEtiology.  This  affection  is  most  frequently  seen  in  individuals  beyond 
middle  age  who  are  subject  to  exposure  and  whose  conditions  of  life  are  poor. 
In  a  few  instances  it  may  follow  acute  articular  rheumatism  and  it  has 
been  known  to  precede  this  type  of  disease. 

Pathology.  The  affected  joint  is  enlarged  and  stiff  as  a  result  of  the  thick- 
ening of  its  capsule  and  of  the  neighboring  tendons  and  their  sheaths;  the 
synovial  membrane  may  be  congested  and  the  joint  cartilages  eroded;  there 
is  occasionally  a  slight  effusion.  In  other  instances  even  with  marked  symp- 
toms there  may  be  little  change  in  the  joint  structures.  Neuritis  of  the 
nerves  about  the  articulation  may  occur  and  with  it  muscular  atrophy  from 
disuse  as  well  as  from  trophic  disorders,  and,  when  marked  effusion  is  pres- 
ent, from  pressure  either  upon  the  muscles  or  the  vessels  which  supply  them. 
In  the  inflammations  of  long  standing  ankylosis  may  take  place. 

Symptoms.  Of  these  the  most  characteristic  are  pain  and  stiffness  of  the 
joints;  these  are  increased  in  cold  and  wet  weather;  motion  augments  the 
pain  but  lessens  the  stiffness;  tenderness  may  be  present  with  shght  swelling; 
redness  is  rare.  Constitutional  manifestations  are  not  common  although 
infrequently  there  may  be  a  slight  rise  in  temperature;  in  the  protracted 
instances  of  the  disease  anaemia,  digestive  disturbances  and  neuralgia  are 
common.  As  the  affection  progresses  the  stiffness  becomes  more  marked, 
there  is  crepitation  on  motion  and  ankylosis  with  deformity  may  take  place. 
Chronic  rheumatism  does  not  tend  to  cause  cardiac  involvement  but  associated 
fibrous  changes  in  the  valves  and  heart  muscle  are  not  uncommon. 

The  prognosis.  While  not  dangerous  to  life  this  disease  tends  to  progress 
and  complete  recovery  is  very  unlikely  to  take  place. 

Treatment.  Salicylic  acid  and  its  salts  are  of  little  use  in  this  form  of 
rheumatism  although  they  may  aid  in  the  relief  of  exacerbations  of  the  disease. 
The  employment  of  drugs  which  benefit  the  patient's  general  condition, 
such  as  iron,  strychnine,  arsenic  and  codliver  oil,  is  to  be  recommended  as 
is  the  use  of  iodine  as  suggested  in  the  section  upon  the  treatment  of  arthritis 
deformans  (p.  283).  In  addition  guaiacol,  i  to  2  minims  (0.065-0.13)  3  times 
a  day  and  tincture  of  guaiac,  10  to  30  minims  (0.66  to  2.0)  at  similar  intervals 
are  beneficial  at  times. 

The  diet  need  be  little  restricted,  for  it  is  important  that  the  nutrition  shall 
be  maintained;  fats,  proteids  and  carbohydrates  in  the  usual  proportions, 
together  with  a  moderate  quantity  of  alcoholic  beverages,  if  these  are  necessary 
to  the  patient's  comfort,  may  be  permitted. 

Exercise  out  of  doors  should  be  continued  as  long  as  the  condition  of  the 


CHRONIC    RHEUMATISM.  277 

patient's  joints  is  sufficiently  mobile  to  render  it  possible.  This  is  to  be 
insisted  upon  and  later  its  lack  should  be  supplied  by  properly  applied 
massage;  vibratory  massage  is  often  beneficial. 

For  the  muscular  atrophy  both  the  faradic  and  galvainc  electric  currents 
should  be  employed  in  connection  with  massage  and  passive  motions. 

Local  applications  are  very  necessary;  the  frequent  application  of  cloths 
wet  in  cold  water  and  covered  with  oiled  silk  is  an  excellent  measure.  Rub- 
bing with  hot  water  may  also  afford  reUef  to  the  pain.  The  joints  should 
be  kept  permanently  wrapped  in  flannel  and  this  protection  will  have  an 
additional  counter-irritant  effect  if  occasionally  moistened  with  equal  parts 
of  guaiacol  and  olive  oil;  dressings  of  10  percent,  ichthyol  ointment  are  also 
effectual.  The  actual  cautery  may  be  employed  as  a  counter-irritant  in 
instances  of  severe  pain  and  often  the  application  of  the  high  frequency 
electric  current  will  afford  great  relief.  BUstering  and  painting  with  iodine 
tincture  have  been  suggested. 

The  hot-air  treatment  is  frequently  of  much  service.  This  consists  of 
placing  the  affected  joint  in  a  specially  constructed  apparatus  in  which  the 
temperature  of  the  air  is  raised  to  250°  F.  (121°  C.)  or  even  higher. 

Hydrotherapeutic  measures  are  very  useful;  those  for  the  well-nourished 
subject  should  be  different  from  those  employed  for  the  weak  and  anaemic. 
For  the  former  the  best  procedure  is  to  give  a  full  bath  lasting  from  10  to  15 
minutes  beginning  at  95°  F.  (35°  C.)  and  gradually  raised  as  high  as  can  be 
borne;  during  the  bath  gentle  massage  should  be  given.  Treatment  at 
one  of  the  alkaline  or  sulphur  hot  springs  often  results  in  great  benefit, 
probably  less  from  any  absorption  of  the  mineral  constituents  of  the 
waters  than  from  the  regular  life,  systematic  bathing  and  freedom  from 
the  cares  of  ordinary  life.  Hot  bathing  can  be  carried  on  at  home  and, 
if  persistently  and  regularly  employed,  should  accomplish  quite  as  good 
results  as  spa  treatment.  After  the  hot  bath  perspiration  should  be  in- 
duced by  a  pack  in  hot  dry  blankets.  This  bath  may  be  taken  daily  or 
less  often  as  the  physician  considers  proper  and  in  the  intervals  the  joints 
may  be  wrapped  in  cold  compresses  as  suggested  above.  As  amelioration 
takes  place  a  hot-air  bath  for  from  10  to  15  minutes  followed  by  a  douche 
bath  at  100°  F.  (37.5°  C.)  reduced  to  90°  F.  (32.5°  C.)  and  succeeded  by  a 
Scotch  douche  to  the  joints  for  about  J  of  a  minute  may  be  employed. 

The  anaemic  patient  should  be  given  hot  baths  with  great  caution  only. 
Two  baths  per  week,  followed  by  the  sweats,  are  usually  all  that  should  be 
advised,  and  the  weakening  effect  of  the  procedure  will  be  better  borne  by 
the  patient  if  a  daily  cool  bath  is  given  as  follows:  While  standing  in  water 
at  100°  F.  (37.8°  C.)  in  a  room  about  70°  F.  (22.5°  C.)  the  patient  is  rapidly 
rubbed  down  with  water  at  80°  F.  (27.5°  C.)  which  is  reduced  a  degree 
or  two  (F.)  each  day.     In  treating  the  anaemic  rheumatic  subject  the  object 


278  CONSTITUTIONAL    DISEASES. 

is  to  use  water  at  as  low  a  temperature  as  possible  consistent  with  a  good 
reaction. 

Scotch  douches  and  cold  and  wet  compresses  applied  to  the  joints  are  use- 
ful adjuncts  to  the  treatment.  Hot-air  baths  followed  by  douches  are  also 
excellent. 

Patients  who  can  afford  it  should  be  advised  to  spend  the  cold  and  wet 
months  in  a  warm  climate. 

MUSCULAR  RHEUMATISM. 

Synonym.     Myalgia. 

Definition.  A  painful  affection  of  the  voluntary  muscles,  their  aponeu- 
roses and  periosteal  attachments,  involving  particularly  the  large  muscles  of 
the  neck,  back  and  limbs  and  the  intercostals. 

etiology.  The  condition  occurs  most  often  as  a  result  of  exposure,  espe- 
cially to  draughts  and  when  overheated  by  exercise;  it  is  consequently  more 
common  in  males.  The  nature  of  the  affection  is  not  definitely  known  and 
various  theories  of  its  origin  have  been  advanced.  It  has  been  considered 
as  due  to  a  lesion  of  the  muscles  themselves,  of  the  inter-muscular  septa  or  of 
the  sensory  nerves  of  the  muscles.  It  is  an  interesting  fact  that  analogous 
symptoms  may  be  caused  by  muscular  strain.  Gout,  rheumatism  and  puri- 
naemic  conditions  predispose  to  the  condition  and  successive  attacks  are  not 
unusual. 

Symptoms.  The  essential  symptom  is  pain,  increased  by  pressure  and 
particularly  by  motion.  While-at  rest  there  may  be  a  dull  ache  or  only  slight 
discomfort  but  attempts  to  use  the  involved  muscles  result  in  very  sharp  and 
cramp-like  pain.  Swelling  may  be  present  but  there  are  no  constitutional 
symptoms  other  than  an  occasional  acceleration  of  the  pulse  or  very  slight 
rise  in  temperature.  The  course  is  often  short,  lasting  no  more  than  a  day 
or  two  or  even  less;  it  may  be  protracted,  however,  long  enough  to  render  the 
term  chronic  not  inappropriate.  Recurrences  are  common  and  those  pre- 
disposed to  the  affection  frequently  suffer  from  muscular  pain  and  stiffness 
in  damp  weather. 

Muscular  rheumatism  occurs  in  several  types,  the  following  being  most 
frequent. 

Lumbago,  as  its  name  signifies,  is  a  painful  affection  of  the  muscles  of  the 
lumbar  region.  It  is  perhaps  the  most  common  form  of  muscular  rheumat- 
ism and  may  be  so  severe  as  to  incapacitate  the  patient  any  movement  of  the 
back  causing  marked  pain. 

Stiff  neck  or  torticollis  affects  the  muscular  tissues  of  the  cervical  region 
and  renders  any  movement  of  the  neck  so  painful  that  the  patient  holds  the 
head  in  the  position  that  affords  himself  the  least  discomfort  and,  when  desiring 


MUSCULAR    RHEUMATISM.  279 

to  turn  it,  turns  the  body;  this  type  of  the  affection  is  frequent  in  the  young 
and  is  usually  unilateral. 

Pleurodynia  results  from  involvement  of  the  intercostal  muscles  and  at 
times  the  pectorales  and  serrati  magni.  The  pain  here  is  very  marked 
for  respiration  necessitates  continuous  movement  of  the  chest.  It  is  usually 
unilateral  and  affects  the  left  side  more  commonly.  It  may  be  differentiated 
from  pleurisy  by  physical  examination  and  from  neuralgia  by  the  absence 
of  tenderness  along  the  course  of  the  nerves. 

Cephalodynia  affects  the  muscles  of  the  scalp,  scapulodynia  those  of  the 
scapular  region,  omodynia  those  about  the  shoulder.  Involvement  of  the 
muscles  of  the  abdomen  and  limbs  may  be  observed. 

Treatment.  The  first  consideration,  and  one  in  which  the  patient  will 
usually  heartily  cooperate,  is  rest.  The  application  of  straps  of  adhesive 
plaster  overlapping  one  another  like  clapboards  and  immobilizing  the  affected 
side  of  the  thorax  is  often  of  great  relief  in  pleurodynia.  Each  strip  of  plaster 
should  extend  about  3  inches  (7.5  cm.)  beyond  the  mid-line  on  both  back  and 
front.  The  rest,  especially  in  aff'ections  of  the  shoulder,  should  not  be  too  pro- 
longed for  stiffness  of  the  joint  and  even  ankylosis  may  result.  Dry  heat  ap- 
plied by  means  of  the  hot  water  bag  or  by  rubbing  the  affected  part  with  a  hot 
flat  iron,  a  layer  of  flannel  being  interposed,  is  often  effectual  in  relieving  the 
pain.  Hot  poultices  may  also  be  used  and  baths  of  steam  may  be  employed. 
Recently  hot-air  apparatus  has  been  specially  constructed  so  that  it  is  possible 
to  bake  any  part  of  the  body  and  the  application  of  hot  air  by  this  means  is  an 
excellent  method  of  treatment ;  upon  the  same  principles  a  Turkish  bath  may 
cut  short  an  attack.  The  application  of  the  high  frequency  electric  current 
is  perhaps  more  effective  than  any  of  the  foregoing  methods  and  when  followed 
by  vibration  massage,  when  this  can  be  borne,  is  highly  to  be  recommended. 
It  is  difficult  to  explain  the  action  of  the  current  but  possibly  it  so  affects 
the  nutrition  of  the  muscle  cells,  or  the  nerves,  if  muscular  rheumatism  is  a 
nerve  disorder,  as  to  bring  about  a  more  normal  state;  certain  it  is  however 
that  many  instances,  particularly  of  chronic  lumbago,  may  be  greatly  benefited 
by  its  application.  The  thermo-cautery  is  also  useful,  blisters  and  cups  have 
a  field  of  usefulness  and,  for  very  severe  pain,  we  may  have  recourse  to  acu- 
puncture, several  heavy  needles  being  plunged  into  the  painful  muscles  and 
allowed  to  remain  for  two  or  three  minutes.  The  hypodermatic  use  of 
morphine  may  become  necessary. 

Liniments  may  be  employed  but  it  is  probable  that  the  benefit  derived  is 
due  quite  as  much  to  the  accompanying  friction  as  to  the  medicament. 

With  regard  to  internal  treatment  it  may  be  said  that  in  a  certain  number 
of  instances  the  administration  of  the  salicylates  may  cause  benefit,  cer- 
tainly a  judicious  trial  will  do  no  harm.  For  the  pain  antipvTine  salicyl- 
ate (salipyrine)  in    10  grain  (0.66)  doses  given  every  hour  for  4  or  5  doses 


2  60  CONSTITUTIONAL    DISEASES. 

and  then  at  longer  intervals  is  often  effective,  and,  empirically,  good  results 
often  follow  the  administration  of  ammonium  chloride,  lo  to  20  grains  (0.66 
to  1.33)  every  i  to  2  hours  up  to  the  limit  of  the  stomach's  toleration;  this 
latter  drug  is  especially  effectual  in  lumbago  and  stiff  neck. 

Persons  subject  to  successive  attacks  should  dress  warmly  and  avoid  over- 
heating and  exposure  of  all  descriptions.  Their  diet  should  be  nutritious 
and  non-irritating  and  tonics,  such  as  codliver  oil,  iron,  arsenic  and  strych- 
nine, should  be  prescribed  if  indicated  and  the  iodides,  nux  vomica,  sulphur 
or  guaiac  may  be  given  in  the  attempt  to  combat  the  chronic  myalgic  tendency. 
Purinasmic  patients  should  be  treated  in  accordance  with  the  suggestions 
offered  under  the  section  devoted  to  the  management  of  this  condition. 


ARTHRITIS  DEFORMANS. 

Synonyms.     Rheumatoid  Arthritis;  Osteoarthritis. 

Definition.  A  chronic  joint  disease  characterized  by  the  occurrence  of 
changes  in  the  intra-  and  peri -articular  structures,  by  atrophy  of  the  bony 
structures  or  the  development  of  osseous  growths  interfering  with  the  joint 
function. 

.Etiology.  This  affection  seems  to  be  rather  more  common  in  females 
than  in  males  and  those  whose  occupations  render  it  necessary  that  the  hands 
should  be  much  in  water  and  thus  subject  to  sudden  and  frequent  changes 
of  temperature,  as  well  as  those  who  are  sterile  or  subject  to  uterine  or  ovarian 
disorders,  appear  to  be  predisposed  to  the  disease.  Heredity  likewise  has 
probably  an  astiological  signiiicance.  The  incipience  of  arthritis  deformans 
usually  takes  place  during  the  third  decade  of  life  but  exceptionally  the  disease 
may  begin  as  early  as  12  or  as  late  as  50  years  of  age. 

The  monarticular  type  of  the  affection  is  probably  a  disease  of  the  central 
nervous  system  and  its  lesions  are  the  result  of  trophic  changes. 

The  polyarticular  type  has  of  late  been  attributed  to  infection  with  some 
as  yet  undiscovered  micro-organism.  While  bacteria  have  been  isolated 
from  the  joint  lesions  their  specificity  remains  to  be  proven. 

Pathology.  There  are  tliree  varieties  of  arthritis  deformans:  a.  The  sym- 
metrical type  in  which  both  upper  extremities  are  involved,  b.  The  unilateral 
form  in  which  the  hand  and  foot  of  the  same  side  are  affected,  c.  The  mon- 
articular type  which  involves  a  single  joint  and  which  is  due  to  a  lesion  of 
the  central  nervous  system. 

The  study  of  the  joint  in  this  disease  by  means  of  the  X-ray  shows  that  in 
certain  instances  the  changes  chiefly  involve  the  intra-  and  peri-articular  struc- 
tures, the  former  being  thickened  and  their  fringes  hypertrophied  and  the 
latter  swollen  and  infiltrated;  fluid  may  be  present  in  the  bursal  and  articular 


ARTHRITIS   DEFORMANS.  28 1 

cavities.  In  other  subjects  the  changes  involve  principally  the  cartilages 
and  bones;  the  former  soften,  become  thin  and  may  become  wholly  absorbed, 
leaving  the  joint  surfaces  bare  and  eburnated,  atrophy  of  the  shafts  may  take 
place  and  nodules  of  bone  develop  at  the  edges  of  the  articulations.  In  still  a 
third  class  of  patients  there  is  bony  hypertrophy;  this  is  particularly  prone  to 
occur  v^hen  the  spinal  column  is  involved  and  may  result  in  ankylosis,  a 
manifestation  which  is  rarely  met  in  other  articulations  as  a  consequence 
of  this  affection. 

Secondary  trophic  changes  and  neuritis  are  not  uncommon;  muscular 
atrophy,  contractures  and  even  disintegration  of  the  ligaments  with  result- 
ing dislocation  (Charcot's  disease)  of  the  joints  may  be  observed.  The 
extremities  are  deformed,  the  hands  being  often  deflected  to  the  ulnar  side. 

Symptoms.  In  the  type  in  which  the  involvement  is  polyarticular,  nodules 
(Heberden's  nodes)  develop  gradually  upon  the  lateral  aspects  of  the  termi- 
nal phalanges,  more  particularly  of  those  of  the  hands;  at  the  beginning  of  this 
manifestation  signs  of  acute  inflammation,  swelling,  pain,  redness  and  ten- 
derness, may  be  present,  and  these  symptoms  may  appear  at  intervals  during 
the  course  of  the  disease  without  assignable  cause  or  as  a  sequence  of  dietetic 
errors.  These  enlargements  may  be  mistaken  for  gouty  tophi  but  are  wholly 
different  both  in  causation  and  composition.  The  joint  cartilages  soften  and 
the  articular  extremities  of  the  bones  become  bare  and  hard.  Patients  in 
whom  the  disease  is  evidenced  by  the  development  of  these  nodosities  are 
likely  to  escape  involvement  of  the  larger  joints  and  are  believed  to  be  likely 
to  enjoy  long  life. 

In  polyarticular  arthritis  deformans  of  the  progressive  type  the  manifes- 
tations may  be  either  acute  or  chronic.  The  former  variety  occurs  especially  in 
females  in  the  third  decade  of  life  and  in  association  with  frequent  pregnancies 
and  lactation;  it  may  also  appear  in  children  and  at  the  climacteric.  The 
attack  is  characterized  by  polyarticular  swelling  and  tenderness  and  a  febrile 
movement;  the  symptoms  persist,  it  may  be  with  remissions,  until  ultimately 
the  permanent  joint  changes  result. 

The  chronic  variety  is  usually  symmetrical,  and  gradual  in  onset  with  pain 
and  swelling,  although  an  acute  attack  may  appear  intercurrently.  Frequently 
one  pair  of  joints  after  another  becomes  involved  until  the  patient  is  wholly 
disabled,  although  quite  frequently  the  finger  joints  are  unaffected.  The 
articulations  may  become  fixed  in  flexion,  especially  those  of  the  knees  and 
hips,  and  muscular  contractions  are  common;  with  these  there  is  an  atrophy 
which  renders  the  articular  enlargements  more  apparent;  while  the  joint 
cavity  may  contain  fluid  it  is  more  often  dry,  motion  being  difl&cult  and  attended 
with  crepitus.  True  bony  ankylosis  does  not  occur  but  the  immobility 
is  due  to  peri-articular  thickening,  adhesions  between  the  articular  cartilages 
and  the  presence  of  bony  outgrowths.     The  presence  of  pain  is  not  constant, 


282  CONSTITUTIONAL    DISEASES. 

in  certain  instances  it  may  be  very  severe,  especially  at  night,  while  in  other 
subjects  the  disease  may  develop  with  comparatively  little  discomfort.  Pain 
on  motion  is  the  rule.  Tingling  and  numbness  of  the  extremities,  cutaneous 
pigmentation  and  glossiness  of  the  skin  over  the  joints  are  not  rare.  The 
affection  is  likely  to  progress,  accompanied  by  increasing  weakness  and 
anaemia,  until  the  patient  is  quite  disabled,  although  at  times  a  stationary 
period  may  be  reached  and  continue,  the  patient  suffering  no  pain  and  the 
general  health  remaining  good,  the  only  inconvenience  being  the  permanent 
disability.  Complications  are  not  common  but  coincident  dyspepsia  and 
anaemia,  during  the  active  stage  of  the  disease's  development  are  frequent. 

The  monarticular  type  of  arthritis  deformans  is  observed  most  frequently 
in  old  men  and  involves  especially  the  hip,  the  knee,  the  shoulder  or  the  joints 
of  the  vertebrae;  a  history  of  traumatism  is  not  rare.  In  the  hip  the  condition 
has  been  termed  morbus  coxa.  There  is  wasting  of  the  muscles  around  the 
affected  joint  and  in  this  respect  as  in  others  the  lesions  are  quite  the  same 
as  those  occurring  in  the  polyarticular  type;  indeed  in  certain  instances  the 
other  joints  may  not  be  entirely  unaffected,  the  corresponding  articulation 
of  the  opposite  side  frequently  showing  changes  of  minor  degree. 

The  vertebral  type  is  characterized  by  a  gradual  progressive  vertebral  anky- 
losis (spondylitis  deformans).  It  occurs  in  two  types;  in  the  one  the  vertebral 
articulations  only  are  affected,  with  associated  nerve  symptoms,  such  as  pain, 
muscular  atrophy,  loss  of  sensation  and  ascending  degeneration  of  the  cord; 
in  the  other  the  nervous  manifestations  are  less  marked  and  there  may  be 
accompanying  affection  of  the  hip  or  shoulder  joints.  It  would  seem  that 
these  two  forms  of  this  type  of  arthritis  deformans  might  better  be  merged 
in  one  as  there  is  little  reason  for  their  separation.  The  condition  may  begin 
in  any  part  of  the  vertebral  column  and  at  times  affects  the  cervical  region 
alone.  It  has  been  thought  to  start  as  a  meningitis  which  by  exerting  pressure 
upon  the  nerve  roots  leads  to  paralysis  of-  the  spinal  muscles  and  ultimate 
ankylosis  of  the  spine. 

In  children  arthritis  deformans  is  a  very  interesting  condition,  it  appears 
before  the  second  dentition  with  fever  in  acute  instances  but  with  merely  joint 
swelling  and  stiffness  in  those  of  subacute  type.  All  the  joints,  including  those  of 
the  vertebrae,  may  be  affected  and  there  are  often  enlargements  of  the  cervical 
and  other  lymph  glands  and  of  the  spleen.  Culture  and  inoculation  experi- 
ments in  this  form  of  the  disease  have  failed  to  reveal  any  evidence  of  tuber- 
culosis. 

The  diagnosis  usually  offers  no  difl&culty,  although  in  subjects  who  present 
an  onset  with  fever  the  condition  may  be  mistaken  for  acute  articular  rheu- 
matism, but  in  the  latter  there  is  a  tendency  to  successive  joint  involvement. 
The  absence  of  tophi  will  distinguish  arthritis  deformans  from  chronic  gout 
but  the  differentiation  of  the  disease  in  its  late  stages  from  chronic  rheumatism 


ARTHRITIS    DEFORMANS.  283 

is  difficult,  in  fact  the  affection  is  considered  by  some  as  an  advanced  form 
of  this  latter  disorder. 

The  prognosis  as  regards  cure  is  distinctly  unfavorable  but  the  disease 
in  no  way  interferes  with  the  continuance  of  life. 

Treatment.  For  the  patients  in  whom  the  onset  is  acute  and  resembles 
that  of  acute  articular  rheumatism  a  treatment,  external  and  internal,  similar 
to  that  of  the  latter  disease  should  be  prescribed.  Of  the  chronic  stage  the 
internal  treatment  should  be  calculated  to  improve  nutrition  in  every  way 
possible  and,  while  we  may  not  be  able  to  influence  the  course  of  the  afiection 
in  any  great  measure,  we  can  accomplish  something  and  the  patient  may  be 
encouraged  with  the  hope  that  the  progress  of  the  disease  may  stop  at  any 
time,  also  with  the  fact  that  periods  of  remission  in  its  development  may  occur. 
The  tonics,  especially  iron  and  iodine,  are  indicated  and  the  judicious  admin- 
istration of  arsenic  is  to  be  recommended.  Iron  may  be  prescribed  in  the 
form  of  the  sulphate  or,  if  this  causes  gastric  disturbance,  iron  vitellin  in  half- 
ounce  doses  (15.0)  will  prove  an  excellent  substitute.  Iodine  may  be  given 
with  iron  in  the  form  of  syrup  of  iron  iodide  or  separately  as  syrup  of  hydriodic 
acid  of  which  i  drachm  (4.0)  should  be  taken  ^  hour  before  each  meal  in  a 
wineglass  (60.0)  of  water.  A  10  percent,  solution  of  iodine  in  oil  of  sesame  may 
also  prove  beneficial;  of  this  10  to  20  drops  (0.66  to  1.33)  may  be  given  every 
3  hours.  Iodine  is  particularly  useful  when  there  is  tendency  to  peri-articular 
thickening  and  it  is  probable  that  its  administration  in  either  of  the  forms 
above  suggested  will  effect  more  benefit  than  will  potassium  iodide;  this  last, 
however,  may  be  employed  if  desired.  In  the  improvement  of  the  general 
nutrition  codliver  oil  is  an  excellent  adjunct  to  the  patient's  diet  which  should 
be  as  generous  as  possible.  The  regimen  should  not  be  restricted  except 
in  so  far  as  to  ehminate  indigestible  and  irritant  foods.  The  bowels  should 
be  kept  freely  open. 

Exercise,  when  practicable,  should  be  advised  and  should  be  taken,  if  pos- 
sible in  the  out-door  air.  Unfortunately,  in  many  instances,  the  nature  of 
the  disease  prevents  systematic  out-door  exercise  and  it  is  here  that  massage 
will  prove  extremely  useful;  by  its  employment  we  successfully  combat  the 
tendency  to  stiffness  of  the  joints,  prevent  in  some  measure  the  muscular 
atrophy  and  diminish  the  infiltration  about  the  articulations. 

Of  other  physical  methods  the  treatment  by  means  of  the  application  of 
hot  dry  air — the  so-called  baking  process — will  benefit  many  patients  and 
should  always  be  tried  even  though  in  a  certain  number  of  instances  it  will 
probably  be  found  ineffective. 

Electricity  in  the  form  of  the  continuous  constant  current  (galvanism)  is 
useful  in  diminishing  the  pain  and  is  often  otherwise  beneficial,  and  the  electric 
bath,  beginning  with  a  rather  weak  current,  may  be  employed.  Static  elec- 
tricity properly  administered  is  often  of  great  benefit. 


284  CONSTITUTIONAL   DISEASES. 

Spa  treatment  and  the  hydrotherapeutic  measures  that  accompany  it  may 
afford  some  rehef.  Hot  baths  of  water,  air  or  steam  are  best  but  should  be 
taken  tentatively  at  first,  for  some  patients  are  made  worse  by  their  employ- 
ment, probably  owing  to  their  depressing  influence  upon  nutrition,  partic- 
ularly when  they  are  taken  in  connection  with  diet  restriction.  It  must  be 
remembered  that  a  full  diet  is  one  of  the  essentials  in  the  treatment  of  this 
disease.  Hydrotherapy  at  home  is  often  practicable  and  hot-air  baths  may 
also  be  taken  in  the  patient's  own  house.  Hot  sand  or  mud  baths  are  often 
beneficial;  the  former  may  be  conveniently  taken  at  home.  The  application 
lo  the  painful  joints  of  hot  wet  or  dry  compresses  is  frequently  effective  in 
lessening  the  pain,  as  also  may  be  the  application  of  the  actual  cautery. 

Orthopaedic  surgery  has  a  field  of  usefulness  in  the  treatment  of  this  disease, 
particularly  in  the  patients  with  spinal  involvement,  the  acute  stage  of  which 
may  be  greatly  benefited  by  means  of  immobilization  with  the  plaster  of  Paris 
jacket.  The  breaking  up  of  the  joint  adhesions  under  anaesthesia  is  some- 
times indicated. 

OBESITY. 

Synonym.     Corpulence. 

Definition.     An  abnormal  accumulation  of  fat  in  the  tissues  of  the  body. 

^Etiology.  Obesity  occurs  in  numerous  instances  as  a  result  of  hereditary 
influence;  it  usually  does  not  appear  until  after  middle  life  but  is  sometimes 
seen  in  children  in  whom  it  is  met  as  a  result  of  improper  feeding.  In  these 
subjects  it  is  often  associated  with  rickets.  While  many  corpulent  persons 
enjoy  excellent  general  health  a  superabundance  of  fat  is  frequently  observed 
in  chlorotic  girls.  Obesity  by  no  means  signifies  that  the  sufferer  is  an  exces- 
sive eater  for  it  is  a  notable  fact  that  many  fat  persons  are  abstemious  in  this 
regard,  perhaps  not  so  much  as' a  result  of  self-denial  as  of  lack  of  appetite. 

Gout  is  an  aetiological  factor  which  is  not  to  be  neglected  but  the  most 
important  cause  is  the  association  of  over-eating  and  too  little  muscular  exer- 
cise. Women,  possibly  because  of  their  greater  proneness  to  a  sedentary 
mode  of  life,  seem  to  be  more  subject  to  obesity  than  men.  The  excessive 
use  of  alcoholic  drinks,  especially  the  malt  beverages,  has  a  direct  influence 
in  the  production  of  this  condition.  The  tendency  of  obesity  to  appear  after 
the  menopause  and  with  the  decline  of  sexual  activity  in  the  male  would  seem 
to  show  that  sexual  indulgence  lessens  the  predisposition  to  its  occurrence. 

Fat  may  be  derived  from  any  one  of  the  three  classes  of  food  and  usually 
obese  persons  are  those  who  eat  largely  of  carbohydrates,  fats  and  proteids, 
the  carbohydrates,  in  the  light  of  our  present  knowledge,  being  less  responsi- 
ble for  fat  production  than  was  formerly  believed. 

Symptoms.  These,  in  the  corpulent  subject  who  is  otherwise  in  good 
health,  consist  merely  of  the  familiar  appearance,  large  round  visage,  multiple 


OBESITY. 


285 


chin,  great  girth,  etc.,  which  one  sees  so  frequently.  As  the  obesity  increases, 
dyspnoea  and  the  symptoms  due  to  fatty  infiltration  of  the  heart  muscle  and 
arteriosclerosis,  such  as  weak  heart  action  and  tendency  to  venous  congestion 
with  oedema,  appear. 

Enlargement  of  the  liver,  due  to  fatty  degeneration  of  the  organ,  is  common 
and  digestive  disorders  are  frequent.  Women  often  suffer  from  gynaecolog- 
ical complaints  and  the  occurrence  of  intertrigo  where,  as  a  result  of  the 
excessive  development  of  fatty  tissue,  two  skin  surfaces  come  into  contact, 
as  in  the  groins,  about  the  labia  and  under  the  breasts,  is  often  observed. 

Treatment.  Prevention  is  necessary  in  subjects  who  show  hereditary  or 
other  tendency  to  become  corpulent;  these  should  be  advised  against  over- 
eating and  the  starches  and  fats  in  the  dietary  should  be  diminished.  Exer- 
cise in  the  fresh  air  should  be  systematically  prescribed;  cool  baths  are  a  nec- 
essary adjunct  to  the  other  measures  if  the  patient's  reaction  is  satisfactory. 

Various  dietetic  treatments  have  been  exploited  most  of  which  bear  the 
names  of  their  originators.  Of  these  it  must  be  said  that  no  stated  method  is 
applicable  to  every  instance  of  the  disease  but  each  patient  should  be  managed 
in  accordance  with  the  existing  indications.  Perhaps  the  best  known  system 
is  that  of  Banting  which  consists  in  the  elimination  from  the  diet  of  carbohy- 
drates and  fats  and  allowing  considerable  amounts  of  proteid  food  in  the  form 
of  lean  meat;  green  vegetables  are  also  permitted.  Water  and  alcoholic 
drinks  are  not  forbidden. 

Ebstein's  dietary  restricts  the  quantity  of  food  ingested  but  allows  fats  and 
carbohydrates  in  considerable  amount,  sweets  and  potatoes,  however,  are 
forbidden. 

Oertel's  system  insists  upon  a  diminution  of  the  ingested  fluids,  only  a  pint 
(500.0)  or  sHghtly  more,  of  water  being  allowed;  fat  is  permitted  in  moderate 
amount  but  not  so  freely  as  by  Ebstein  while  the  proteids  and  carbohydrates 
are  less  restricted  than  by  this  cHnician.  The  fluids  are  restricted  on  the  ground 
that  they  increase  any  circulatory  diflaculty  which  may  be  present. 

The  following  table  gives  certain  dietaries  expressed  approximately,  com- 
pared with  the  generally  accepted  requirements  of  an  average  adult  at  moder- 
ate work;  the  solid  constituents  are  reckoned  as  being  free  from  water. 


Dietary. 

Proteids. 

Fats. 

Carbohydrates. 

Caloric 
\'alue. 

Fluid  as 
Beverage. 

Normal  -    -    - 

oz. 

3^  (105.0) 

oz. 
3  fgo.o) 

oz. 

14  {420.0) 

3.000 

Pts. 
3-4   (1,500-2,000) 

Harvey-Banting 

6  {180.0) 

\  (10.0) 

2^^  (75.0) 

1,100 

2    (1,000) 

Oertel    -    -    -    - 

5^2-6^2  (165.0-195.0) 

1-1^2   (30.0-45  0) 

2^2-3^2  (75.0-105.0) 

1,200-1,600 

I-1V2  (500-750) 

Ebstein      -    -    - 

3^2    (105.0) 

3  (90.0) 

1%    (S2.0) 

1,300 

3    (1,500) 

Von  Noorden    - 

5^  (165.0) 

I  (30.0) 

3^  (105.0) 

I.3S0 

2   (1,000) 

286  CONSTITUTIONAL    DISEASES. 

Dujardin-Beaumetz  recommends  the  following  regimen:  Breakfast  at 
7  A.  M.  to  consist  of  6^  drachms  (25.0)  of  bread;  12^  drachms  (50.0)  of  cold 
meat  without  fat  and  6  ounces  (180.0)  of  weak  tea.  Luncheon  at  noon  con- 
sisting of  12^  drachms  (50.0)  of  bread,  the  crust  being  preferable  to  the  soft 
part;  3  ounces  (90.0)  of  meat  or  two  eggs;  3  ounces  (90.0)  of  green  vege- 
tables; a  salad;  3  drachms  (12.0)  of  cheese  and,  for  dessert,  cooked  fruit  of 
any  desired  variety.  Dinner  at  7  P.  M.  No  soup;  12^  drachms  (50.0)  of 
dry  bread;  3  ounces  (90.0)  of  meat  and  vegetables,  salad,  cheese  and  fruit 
as  at  luncheon.  The  fluids  are  reduced  and  pastry  and  sweets  are  forbidden. 
Starches  are  cut  down  to  a  minimum  and  the  only  alcohol  allowed  is  half  a  glass 
of  a  light  white  wine  with  the  two  principal  meals.  Alkaline  waters  are  also 
permitted  and  the  patient  may  take  a  small  sup  of  black  coffee  after  dinner. 
Still  better  than  to  take  fluids  with  the  meals  is  to  omit  them  at  these  times 
and  to  drink  about  two  hours  after  eating  a  glass  of  white  wine  mixed  with  two 
parts  of  water,  or,  if  preferred,  a  large  cup  of  weak  tea  without  sugar.  With 
some  patients  it  may  be  more  advantageous  to  give  small  quantities  of  proper 
food  in  the  intervals  of  the  meals  lest  the  reduction  of  the  diet  produce  weak- 
ness. The  importance  of  institutional  treatment  in  connection  with  diet 
regulation  cannot  be  over-rated,  for  the  systematic  exercise,  bathing,  etc.,  that 
can  be  carried  on  at  a  hospital  or  sanatorium  are  very  essential  adjuncts  to 
the  successful  management  of  patients  suffering  from  obesity. 

The  oxidation  of  the  fats  of  the  body  may  be  accelerated  by  stimulation 
of  the  skin  by  means  of  massage  although  in  some  instances  this  procedure 
is  not  successful  in  reducing  flesh.  Hydrotherapeutic  measures  are  also 
indicated,  cold  fresh  or  sea  baths  being  preferable  for  some  patients  while 
others  are  more  satisfactorily  treated  if  Turkish  and  steam  baths  are  pre- 
scribed; the  latter  should  be  followed  by  douches  and  massage. 

Obese  subjects  should,  when  possible,  take  regular  muscular  exercises 
such  as  walking,  bicycling,  horseback  riding  or  gymnastics. 

Too  much  sleep  predisposes  to  corpulence  and  most  patients  will  do  well 
to  limit  their  slumber  to  six,  or  at  most  eight  hours. 

It  is  often  wise  to  stimulate  the  liver,  which  in  many  instances  is  sluggish 
in  its  action;  this  may  be  accomplished  by  prescribing  Carlsbad  or  Kissingen 
salts  or  even  sodium  or  magnesium  sulphate. 

The  spa  treatment,  as  carried  on  at  Carlsbad,  Marienbad  and  other  like 
resorts,  is  often  successful  in  reducing  the  weight  of  over-fat  subjects  and 
manv  such,  after  a  few  weeks'  sojourn,  will  exhibit  marked  improvement  evi- 
denced by  amelioration  of  the  unpleasant  symptoms  of  the  obesity  as  well 
as  by  loss  of  body  weight.  This  is  probably  the  result  of  the  systematic  and 
regular  mode  of  life  combined  with  the  use  of  laxative  waters  and  a  reduced 
diet.  The  management  of  obesity  by  means  of  a  few  weeks'  stay  at  a  resort, 
while,  during  the  rest  of  the  year  the  patient  regulates  his  habits  to  suit  him- 


SCURVY.  287 

self,  is  far  less  to  be  recommended  than  a  slow  and  continuous  method  of 
treatment. 

The  administration  of  thyroid  extract  in  conditions  of  obesity  has  come 
into  vogue  during  recent  years  and  it  may  bring  about  a  loss  of  weight  in 
certain  instances  in  which,  perhaps,  the  corpulence  is  the  result  of  disordered 
function  of  the  thyroid  gland.  The  dried  extract  is  the  preparation  to  be 
preferred  and  its  usual  dose  for  an  adult  is  from  3  to  5  grains  (0.2  to  0.33) 
three  times  daily.  It  is  not,  however,  a  drug  to  be  carelessly  used  and  its 
effects  should  be  watched  (see  the  treatment  of  myxoedema). 

The  administration  of  iodine  with  the  alkaline  iodides  has  also  been  sug- 
gested and  these  may  be  prescribed  in  the  following  formula.  Metallic  iodine 
i^  grains  (o.i),  potassium  iodide  22^  grains  (1.5),  water  to  i  ounce  (30.0); 
of  this  a  teaspoonful  should  be  taken  3  to  4  times  a  day.  The  alkaline  salts 
of  lithium,  potassium  and  sodium  may  also  be  given  thus:  potassium  carbo- 
nate i^  parts;  lithium  carbonate  2  parts;  sodium  bicarbonate  and  potas- 
sium iodide  of  each  6  parts;  water  to  300  parts;  the  dose  of  the  mixture  being 
2  to  3  dessertspoonsful  (8.0  to  12.0)  daily. 

SCURVY. 

Synonym.    Scorbutus. 

Definition.  A  disease  characterized  by  anaemia,  general  weakness,  a 
spongy  condition  of  the  gums  and  a  tendency  to  haemorrhages  from  the  skin 
and  mucous  membranes. 

.Etiology.  Formerly  scurvy  was  very  common  among  sailors  upon  long 
voyages  where  it  was  impossible  to  arrange  a  dietary  containing  fresh  vege- 
tables and  from  this  fact  the  incidence  of  the  disease  was  considered  to  be  due 
to  the  lack  of  these  articles  of  food,  particularly,  as  with  the  better  methods 
of  preserving  food  and  with  the  quicker  voyages  which  are  in  evidence  to- 
day, the  affection  has  all  but  disappeared.  However,  since  it  has  been  shown 
that  scurvy  occurs  epidemically,  endemically  and  sporadically,  independently 
of  dietetic  conditions,  and  that  it  may  not  appear  when  nothing  but  meat  is 
eaten  for  months  at  a  time,  the  theory  that  the  disease  is  due  to  a  lack  of  vege- 
table elements  in  the  food  has  been  greatly  shaken.  That  it  may  appear  as  a 
result  of  a  diet  from  which  vegetables  are  wholly  or  in  part  absent  is  probable 
unless  a  large  number  of  reported  instances  in  individHals  who  have  subsisted 
for  considerable  periods  upon  such  articles  as  meat,  bread,  tea  and  coffee  have 
been  coincidences. 

Certain  observers  have  attributed  scurvy  to  the  deficiency  in  the  diet  of 
the  potassium  salts  and  others  to  the  lack  of  the  alkaline  carbonates  derived 
from  the  vegetable  acids. 

Another  theory  of  the  causation  of  the  disease  is  that  it  results  from  some 


266  CONSTITUTIONAL    DISEASES. 

toxic  substance  produced  by  the  decomposition  of  food.  This  hypothesis 
is  supported  by  the  fact  that  an  affection  analogous  to  scurvy  has  been  induced 
in  apes  by  feeding  them  upon  shghtly  decayed  food. 

A  third  view  of  the  aetiology  of  scorbutus  is  that  it  is  an  infection  and  due 
to  a  micro-organism  which  is  as  yet  not  isolated.  A  bacterium  has  been 
found  occurring  in  instances  of  the  disease  which,  when  cultivated  and  inocu- 
lated into  lower  animals,  causes  symptoms  and  lesions  resembling  those  of 
sciurvy;  the  relation  of  this  organism  to  the  disease  is  not  yet  definitely  proven. 

As  predisposing  causes  we  may  mention  over-crowding  under  unhygienic 
conditions,  such  as  obtain  on  ships,  in  army  camps,  asylums,  etc.,  exposure 
to  cold  and  wet,  and  mental  and  physical  over-work.  The  principal  factor 
is,  however,  the  eating  of  improper  food  for  a  considerable  period. 

Pathology.  The  changes  in  the  blood  are  not  characteristic  of  anything 
more  than  marked  anaemia;  there  is  no  increase  in  the  number  of  leucocytes. 
The  blood  itself  is  dark  and  fluid.  Haemorrhages  in  any  part  of  the  body 
may  be  observed;  into  the  skin,  mucous  membranes,  muscles  or  other  tissues; 
they  may  take  place  even  into  the  joints.  Bleeding  into  the  liver,  kidneys 
and  muscles  may  be  accompanied  by  degenerative  changes.  The  spleen 
is  enlarged  and  softened  and  there  is  swelling  of  the  gums,  in  some  instances 
so  pronounced  that  the  teeth  fall. 

Symptoms.  The  onset  is  usually  gradual  with  increasing  emaciation  and 
weakness;  the  skin  is  pale,  the  tissues  about  the  eyes  are  swollen  and  bluish. 
Dyspnoea  on  exertion  with  palpitation  may  be  present  and  the  patient  may 
complain  of  muscular  and  joint  pains.  The  gums  become  soft,  swollen  and 
spongy,  they  blSed  easily,  may  be  ulcerated  and  the  teeth  may  become  loose 
and  drop  out.  The  breath  is  foul  and  the  tongue  red  and  swollen;  rarely 
there  may  be  necrosis  of  the  jaw. 

Petechial  haemorrhages  are  noticed,  first  upon  the  legs,  later  upon  the  upper 
limbs  and  body.  As  the  disease  progresses  the  haemorrhages  become  larger; 
they  are  dark  red,  rounded,  and,  when  directly  under  the  skin,  may  cause  cir- 
cumscribed tumors.  They  are  less  common  in  the  mucous  membranes  but 
may  take  place  under  the  periosteum  and  into  the  serous  membranes.  Sub- 
periosteal haemorrhages,  especially  in  the  legs,  may  break  down  into  sluggish 
sores.  Bleeding  results  from  the  least  traumatism;  epistaxis  is  common 
but  haematvu-ia  and  bloody  stools  are  less  frequent;  haemoptysis  and  haema- 
temesis  are  very  seldom  noted. 

(Edema  of  the  ankles  is  common  and  the  urine  may  contain  albumin. 
The  patient  suffers  from  weakness;  mastication  is  painful  and  the  appetite  is 
poor.  The  bowels  are  usually  constipated.  The  heart  is  irregular  and  feeble 
and  the  functional  murmur  of  anaemia  may  be  heard  over  the  second  left  space 
close  to  the  sternum.  The  temperature  is  seldom  elevated.  Haemorrhagic 
infarcts  of  the  lungs  or  spleen  may  occur. 


SCURVY.  289 

Mental  symptoms,  such  as  depression  and  insomnia,  are  common;  delirium 
is  a  late  symptom;  meningeal  haemorrhage,  convulsions  and  paralyses  have 
been  observed,  as  have  hemeralopia  and  nyctalopia. 

The  diagnosis  is  simple  when  a  number  of  instances  of  the  disease  appear  at 
the  same  time  and  place.  The  haemorrhages  and  spongy  condition  of  the  gums 
are  fairly  characteristic  and  when  these  occur  in  connection  with  an  improper 
diet  and  disappear  when  proper  food  is  prescribed  the  diagnosis  is  assured. 

The  prognosis  in  the  early  stages  is  good  but  later  the  tendency  to  serious 
complications  such  as  infarct,  pleural  or  meningeal  haemorrhage,  nephritis, 
etc.,  renders  it  less  favorable. 

Treatment.  Prophylaxis  consists  in  so  regulating  the  supplies  taken  by 
ships  on  long  voyages  that  there  shall  be  a  sufficient  amount  of  fresh  vegetable 
food;  this  has  been  done  by  law.  Free  ventilation  and  avoidance  of  damp- 
ness are  to  be  advised. 

The  treatment  of  the  disease  is  chiefly  dietetic.  The  juice  of  two  or  three 
lemons  or  oranges  should  be  taken  daily,  in  connection  with  a  regimen  con- 
taining plenty  of  fresh  meat  and  green  vegetables,  such  as  lettuce,  water-cress, 
spinach,  onions,  cabbage,  celery,  etc.,  and  will  cause  a  rapid  amehoration  of 
all  the  symptoms.  If  the  digestion  is  so  impaired  that  careful  feeding  is  nec- 
essary the  fruit  juices  should  be  given  together  with  milk,  beef  juice,  scraped 
beef,  gruels  and  other  easily  digestible  foods  until  a  tolerance  for  ordinary 
articles  is  established,  when  eggs,  potatoes  and  the  substances  mentioned 
above  may  be  gradually  allowed.  A  sluggish  digestion  may  be  stimulated  by 
giving  the  vegetable  bitters,  strychnine,  quinine,  etc.,  and  it  is  often  advisable 
to  add  iron  in  order  to  assist  the  regeneration  of  the  blood.  An  excellent 
preparation  is  the  elixir  of  strychnine,  quinine  and  iron  of  the  national  for- 
mulary. Necessary  adjuncts  to  treatment  are  moderate  exercise,  bathing 
and  regulation  of  the  general  hygiene. 

The  various  symptoms  should  be  treated  as  they  occur.  For  the  gingivitis 
astringent  and  antiseptic  mouth  washes  should  be  prescribed.  Swabbing 
the  gums  with  2  percent,  tannic  acid  or  5  percent,  silver  nitrate  is  an  excellent 
measure.  A  satiurated  solution  of  potassium  chlorate  is  serviceable  if  ulcers 
are  present  and  potassium  permanganate  i  to  5000  or  Dobell's  solution  makes 
a  useful  mouth  wash. 

For  the  haemorrhages  surgical  means  should  be  employed  when  necessary, 
and  the  administration  of  calcium  lactate  or  chloride  in  20  grain  (1.33)  doses 
3  times  daily  is  a  very  effective  measure  in  checking  these  manifestations, 
owing  to  the  influence  of  these  salts  in  increasing  the  rapidity  of  the  coagu- 
lation of  the  blood.  The  injection  of  solutions  of  gelatin  has  also  been 
suggested  in  haemorrhage  but  is  less  to  be  depended  upon  than  the  adminis- 
tration of  the  calcium  salts.  The  same  may  be  said  of  other  internal  haemos- 
tatics; these,  however,  may  be  used  if  desired. 
19 


290  CONSTITUTIONAL    DISEASES. 

The  constipation  may  be  controlled  by  means  of  intestinal  irrigations. 

Ulcerations  upon  the  limbs  require  surgical  treatment  as  does  separation 
of  the  epiphyses  which  sometimes  occurs. 

The  complications,  cardiac,  pulmonary,  renal,  etc.,  should  be  treated  as 
when  occurring  independently. 

INFANTILE  SCURVY. 

Synonym.     Barlow's  Disease. 

Definition.  A  disease  of  infants  analogous  to  scurvy  as  observed  in  adults 
and  often  associated  with  rickets. 

.Etiology.  Infantile  scorbutus  is  due  to  improper  feeding;  in  most  instances 
the  disease  occurs  between  the  6th  and  the  15th  month  and  it  is  often  seen  in 
the  best  class  of  private  practice.  Exactly  what  the  cause  of  the  affection 
is,  it  is  at  present  impossible  to  state,  we  merely  know  that  it  is  the  result  of  a 
lack  of  something  in  the  food  which  is  essential  to  normal  nutrition.  The 
condition  is  most  frequently  observed  in  infants  who  have  been  fed  upon 
proprietary  foods,  sterilized  or  condensed  milk;  it  has  also  been  reported 
in  breast-fed  babies.  As  a  rule  several  months  of  improper  feeding  are  nec- 
essary to  the  development  of  the  disease. 

Pathology.  The  most  constant  and  characteristic  lesions  are  haemor- 
rhages beneath  the  periosteum,  especially  that  of  the  bones  of  the  legs.  Inter- 
muscular and  peri-articular  extravasations  may  also  be  present.  There  may 
be  epiphyseal  separations  in  extreme  instances  of  the  disease;  changes  in  the 
bones  analogous  to  those  of  rickets  may  be  observed.  Haemorrhages  into 
the  skin,  mucous  membranes,  the  serous  sacs  and  the  viscera  are  sometimes 
found. 

Symptoms.  The  onset  is  usually  gradual  with  loss  of  flesh,  increasing 
paleness  and  fretfulness.  Soon  tenderness  and  pain  upon  motion  of  the 
limbs  is  noticed;  at  first  this  is  observed  only  when  the  child  is  handled,  later 
it  becomes  constant;  swelling  above  the  ankles  may  be  present.  The  gums 
are  swollen,  spongy  and  tend  to  bleed  upon  irritation  or  even  spontaneously, 
they  are  purplish  in  co^or  and  may  obscure  the  teeth.  Ecchymoses  in  the 
neighborhood  of  the  large  joints  may  appear.  The  increasing  muscular 
weakness  may  be  mistaken  for  paralysis.  Ultimately  the  patient  becomes 
anaemic,  cachectic  and  emaciated;  haematemesis,  melaena  or  haematuria  may 
occur  and  late  in  the  disease  there  may  be  a  slight  febrile  movement ; 
exophthalmos  due  to  orbital  haemorrhage  may  be  noted.  Epiphyseal  sepa- 
rations are  late  symptoms  and  usually  result  from  trauma.  Albuminuria 
with  casts  is  not  infrequent  and  most  scorbutic  children  suffer  from  gastric 
and  intestinal  derangement. 

The  diagnosis.     Infantile  scurvy  may  be  differentiated  from  rheumatism 


RICKETS.  291 

by  the  age  of  the  patient,  the  condition  of  the  gums  and  the  history  of  the 
dietary,  and  from  poUomyeUtis  by  the  pain  and  tenderness. 

The  prognosis,  when  the  disease  is  recognized  early  in  its  course,  is  good, 
the  recovery  under  treatment  being  very  rapid;  only  very  rarely  are  permanent 
lesions  left  behind.  Unrecognized  instances  may  terminate  fatally  in  three 
to  four  months  from  cachexia,  heart  failure  or  intercurrent  disease 

Treatment.  The  patient  should  be  immediately  put  upon  cow's  milk 
properly  modified  in  accordance  with  its  age  and  digestive  ability.  In  addi- 
tion fresh  fruit  juice,  preferably  that  of  the  orange,  should  be  prescribed;  this 
should  be  given  about  half  an  hour  before  feeding  and  in  total  daily  quantity 
of  ^  ounce  to  4  ounces  (15.0  to  120.0)  depending  upon  the  age  and  tolerance 
of  the  child.  Even  when  diarrhoea  is  present  the  fruit  juice  is  not  always 
contraindicated,  this  manifestation  often  being  a  symptom  of  the  scurvy 
and  one  which  becomes  rapidly  ameliorated  under  this  treatment.  The 
expressed  juice  of  fresh  beef  may  also  be  given,  and,  if  the  patient  is  of  proper 
age,  fresh  vegetables  are  valuable  adjuncts  to  treatment. 

The  anaemia  and  poor  general  condition  often  render  advisable  the  admin- 
istration of  codliver  oil,  the  syrup  of  iron  iodide,  and  other  tonics;  these  should 
seldom  be  prescribed  before  the  scorbutic  symptoms  have  disappeared. 

Epiphyseal  separation  necessitates  orthopaedic  treatment  in  connection 
with  the  measures  above  suggested.  Fortunately  the  separations  are  seldom 
permanent. 

RICKETS. 

Synonym.     Rhachitis. 

Definition.  A  disease  of  infantile  nutrition  characterized  chiefly  by  anom- 
alies in  the  development  of  the  bones  and  consequent  deformities. 

.Etiology.  Rarely  the  affection  is  congenital.  It  occurs  far  more  fre- 
quently in  cities  than  in  the  country  and  is  more  common  in  Europe  than  in 
America.  It  is  particularly  frequent  in  the  ItaHans  and  negroes  of  the  United 
States,  probably  because  the  native  habitat  of  these  races  offers  a  warmer 
climate  than  ours.  It  occurs  especially  amongst  the  children  of  the  poorer 
classes  because  of  the  vitiated  hygienic  conditions  in  which  these  unfortunates 
are  compelled  to  exist.  In  Russia  it  is  said  to  appear  commonly  in  the  families 
of  the  well-to-do,  the  climate  of  this  country,  in  its  northern  part  at  least, 
being  such  as  to  render  free  ventilation  uncomfortable.  Dense  crowding 
and  lack  of  sunlight  seem  to  be  important  predisposing  causes.  An  unsuitable 
or  insufficient  diet  is  the  most  essential  setiological  factor  and  consequently 
the  disease  is  more  often  observed  in  artificially  fed  infants  than  in  those  fed 
from  the  breast;  it  does,  however,  appear  in  breast-fed  children  when  the 
milk  is  not  of  good  quality  and  also  when  the  child  is  not  weaned  at  a  proper 
time.     Infants  fed  upon  sterilized  or  condensed  milk  or  upon  proprietary 


292  CONSTITUTIONAL    DISEASES. 

foods  are  especially  prone  to  the  affection  which  seems  here  to  be  due  to  a 
lack  of  sufficient  fat  and  proteid  matter  in  the  dietary,  in  consequence  of 
which  there  is  for  some  reason  a  defective  assimilation  of  the  calcium  salts. 

Syphilis  may  co-exist  with  rickets  but  the  latter  is  not  a  manifestation  of 
the  former  disease  although  it  may  be  modified  by  it. 

Sex  has  nothing  to  do  with  the  incidence  of  rickets;  the  disease  usually 
shows  itself  between  the  6th  and  15th  month  but  the  so-called  late  rickets 
may  not  appear  until  the  loth  or  12th  year  of  life. 

Pathology.  The  lesions  are  chiefly  of  the  osseous  system,  particularly 
the  bones  of  the  cranium,  the  long  bones  and  the  ribs.  The  skull  tends 
toward  the  cubical  in  shape,  the  vault  and  occiput  being  flattened  while  the 
frontal  and  parietal  eminences  become  more  pronounced.  The  head  is 
enlarged  and  the  forehead  bulging.  The  closure  of  the  fontanelles  is  delayed, 
even  until  the  third  year,  the  margins  of  the  bones  being  thickened  and  soft. 
Foci  of  delayed  ossification  which  yield  to  pressure  may  be  present  in  the 
parietal  or  occipital  regions. 

The  epiphyseal  cartilages  of  the  long  bones  are  enlarged  as  a  result  of  the 
rapid  thickening  of  the  zone  of  proliferation,  which  is  bluish  in  color  and  soft 
and  spongy.  The  periosteum  is  easily  detachable,  revealing  a  spongy  bone 
markedly  deficient  in  the  lime  salts.  The  bones  bend  easily,  producing 
deformities  which  are  particularly  evident  in  the  tibiae  as  a  result  of  the  pres- 
sure of  the  body  weight  or  are  produced  by  sitting  cross-legged.  The  femora 
also  may  be  bowed  outward  or  forward.  The  humerus  is  often  bent  and  the 
radius  and  ulna  may  be  twisted  out  of  shape.  Exaggeration  of  the  normal 
curves  of  the  clavicle  is  not  infrequent. 

The  chest  is  characteristically  deformed;  a  vertical  groove  may  be  present 
between  the  4th  and  8th  ribs  upon  its  lateral  aspects  producing  the  "chicken- 
breast."  Accompanying  this  deformity  the  so-called  Harrison's  groove  may  be 
observed;  this  is  a  transverse  depression  extending  from  the  xiphoid  cartilage 
toward  the  axilla.  The  "rickety  rosary"  is  also  frequent.  This  term  is 
applied  to  the  bead-like  nodules  which  appear  at  the  junctions  of  the  ribs 
with  their  cartilages. 

Spinal  curvatures  are  common,  the  normal  dorsal  convexity  and  the  lumbar 
lordosis  being  accentuated.  Scoliosis,  also,  is  not  rare.  Thickening  of  the 
scapulas  and  the  well-known  rhachitic  deformity  of  the  pelvis  are  often  ob- 
served, the  iliac  bones  being  distorted,  the  antero-posterior  diameter  of  the 
true  pelvis  diminished,  and  the  pubic  arch  narrowed. 

The  bony  deformities  are  due  to  the  tension  of  the  muscles  or  to  the  pres- 
sure of  the  body  weight. 

Upon  chemical  analysis  the  bones  in  rickets  are  found  to  contain  a  super- 
abundance of  organic  matter  and  a  greatly  diminished  proportion  of  the 
lime  salts. 


RICKETS.  ,  293 

The  muscles  are  small  and  poorly  developed  and  the  abdomen  is  usually 
enlarged  and  prominent.     (Lucas's  sign.) 

Various  lesions  of  the  viscera  are  common.  Collapse  of  the  lung  may  be 
present  beneath  the  lateral  grooves  of  the  thorax;  bronchitis  and  broncho- 
pneumonia are  frequent  and  mild  gastric  and  intestinal  catarrh  with  dilata- 
tion may  be  observed.  Splenic  enlargement  (simple  hyperplasia)  is  often 
noted  and  the  liver  may  be  increased  in  size.  Enlargements  of  the  lymphatic 
glands  often  occur  but  are  merely  associated  lesions. 

Symptoms.  Many  of  these  have  been  dealt  with  in  discussing  the  pathology 
of  the  disease.  The  onset  is  usually  gradual  and  as  a  rule  appears  before 
the  15th  month;  one  of  the  earliest  symptoms  is  sweating  of  the  head,  espe- 
cially at  night  and  often  so  profuse  as  to  wet  the  pillow;  the  child  sleeps  rest- 
lessly, and  may  exhibit  a  slight  febrile  movement  and  digestive  disturbances 
such  as  nausea,  regurgitation  of  food,  flatulence  and  constipation.  He  is 
poorly  nourished,  dentition  is  delayed  and  the  teeth,  when  they  appear,  are 
often  poorly  formed  and  decay  quickly.  Tetany  and  laryngismus  stridulus 
are  not  infrequent  and  rickets  is  a  very  important  predisposing  cause  of 
infantile  convulsions,  these  being  usually  excited  by  some  digestive  disorder. 
Tenderness  over  the  epiphyses  may  be  present  causing  the  child  to  cry  when 
lifted  or  otherwise  disturbed. 

The  first  symptom  to  appear  referable  to  the  osseous  system  is  the  beading 
of  the  ribs  and  is  a  very  constant  manifestation.  In  very  young  infants  as  an 
early  symptom  soft  spots  may  be  observed  over  the  occipital  or  parietal  bones 
which  crackle  somewhat  like  parchment  upon  pressure.  This  condition  is 
termed  cranio-tabes  and  may  occur  in  congenital  syphilis  both  with  and 
without  rickets.  The  other  bony  deformities  have  been  described  in  the 
section  devoted  to  pathology.  The  fontanelles  are  late  in  closing,  often 
persisting  until  the  child  is  2J  years  old,  the  forehead  is  protuberant  and  the 
face  relatively  small  and  of  a  prematurely  aged  expression;  the  veins  of  the 
scalp  are  often  conspicuous  and  the  hair  over  the  occiput  is  thinned  owing 
to  the  friction  of  the  pillow. 

The  ligaments,  especially  those  of  the  large  joints,  are  loosened  and  stretched, 
causing  the  weak  ankles,  the  backward  bowed  knees  and  the  abnormal  mobility 
of  other  articulations  which  are  so  often  seen  in  rickets. 

The  muscles  are  flabby  and  small  and  their  consequent  weakness  causes 
walking  to  be  delayed  and  interferes  also  with  standing  and  sitting  upright. 
The  lack  of  power  in  the  ill-developed  muscles  may  be  so  marked  as  to  render 
the  differentiation  from  a  true  paralysis  impossible  except  by  testing  the 
reaction  to  electricity.  The  lack  of  muscular  tone  is  also  in  great  measure 
responsible  for  the  prominent  abdomen  and  the  constipation. 

Rhachitic  children  are  usually  fat  but  their  flesh  is  not  firm  and  they  are 
anaemic;    they    frequently    exhibit    lymphatic    enlargements,    hypertrophied 


294  CONSTITUTIONAL   DISEASES. 

tonsils  and  adenoids  and  fall  an  easy  prey  to  any  acute  disease,  being  par- 
ticularly prone  to  all  affections  of  the  mucous  membranes  of  the  respiratory 
or  digestive  tracts.  The  condition  of  the  blood  is  not  typical;  anaemia  is 
usually  present  in  varying  degrees  and  the  leucocytes  may  or  may  not  be 
increased  in  number. 

The  liver  and  spleen  are  often  palpable  either  as  a  result  of  enlargement 
or  of  the  downward  pressure  of  the  thoracic  deformities. 

The  diagnosis  is  seldom  diflScult.  Rickets  is  to  be  differentiated  from 
syphilis  by  the  facts  that  in  the  former  disease  the  bone  affections  are  at  the 
epiphyses  rather  than  in  the  extremities  or  shafts,  that  necrosis  never  occurs 
and  that  the  enlargements  are  of  the  bones  themselves,  while  in  syphilis  they 
appear  rather  like  soft  swellings  over  the  bone.  In  scurvy  there  are  the 
typical  gum  lesions  and  the  haemorrhages,  and  the  various  paralytic  condi- 
tions may  be  separated  from  rickets  with  extreme  muscular  weakness  by 
testing  the  electrical  reactions,  and  the  patellar  reflexes  and  by  studying  the 
cerebral  condition. 

The  spine  of  rickets  is  flexible,  the  curves  are  less  acute  than  those  of  Pott's 
disease  and  disappear  when  the  patient  is  laid  flat.  The  other  symptoms 
of  rickets  are  present,  and  these,  with  the  absence  of  the  characteristic  mani- 
festations of  tuberculous  hip  and  congenital  dislocation,  render  the  differ- 
entiation of  the  former  affection  from  the  two  latter  conditions  a  simple 
matter. 

The  prognosis  is  favorable,  rickets  alone  never  resulting  fatally.  There  is 
always  danger  that  the  child  may  fall  a  victim  to  complicating  disease.  The 
course  is  chronic,  the  symptoms  often  continuing  for  months.  Their  prog- 
ress usually  ceases  at  the  age  of  about  one  and  a  half  years  probably  because 
the  diet  by  this  time  has  become  more  general  and  the  child  is  allowed  more 
in  the  open  air.  Under  proper  treatment  gradual  improvement  takes  place. 
The  health  of  the  patient  is  not  permanently  impaired  unless  there  is  marked 
deformity  of  the  chest,  although  the  bowing  and  shortening  of  the  legs  may 
prevent  him  reaching  normal  stature. 

Treatment.  Rickets  being  to  a  great  extent  a  preventable  disease  and  due 
to  improper  feeding  and  unhygienic  surroundings,  the  prophylaxis  consists 
in  the  avoidance  of  these  factors  in  the  causation  of  the  affection.  When 
previous  children  have  suffered  from  rickets  those  who  follow  are  markedly 
predisposed  to  the  affection  and  upon  this  account  should  be  the  more  carefully 
guarded. 

Treatment  proper  consists  primarily  in  diet  regulation.  Breast-fed  babies 
when  rickety  should  be  artificially  fed  with  properly  modified  cow's  milk  unless 
a  wet  nurse  whose  milk  is  of  normal  composition  is  available.  Older  children 
who  are  able  to  take  food  other  than  milk  should  be  given  a  diet  consisting 
chiefly  of  proteids  and  fats,  carbohydrates  being  excluded  as  far  as  possible; 


RICKETS.  295 

milk,  cream,  beef  juice,  eggs,  red  meat  and  fresh  fruit,  either  raw  or  stewed, 
should  make  up  the  greater  part  of  the  regimen.  Farinaceous  foods,  and  par- 
ticularly the  proprietary  infant  foods,  should  be  interdicted. 

Hygienic  treatment  is  at  least  as  important  as  diet  regulation  and  often 
more  difficult  to  arrange.  Fresh  air,  sunshine  and  out-door  life  are  absolutely 
essential,  consequently  city  children  should  if  possible  be  removed  to  the 
country,  or,  if  this  is  impracticable,  the  patient  should  spend  as  much  time  as 
possible  in  the  parks  or  upon  the  roof  where  oftentimes  a  sort  of  play-ground 
can  be  constructed.  Free  ventilation  of  living  and  sleeping  rooms  is  essential 
and  the  mother  may  be  assured  that,  if  properly  clothed  and  protected  from 
draughts,  the  child  will  be  in  no  danger  if  the  window  of  the  sleeping  room 
is  kept  open.  Flannel  night  drawers  with  feet,  and  warm  coverings  are  to 
be  advised  and  as  a  hardening  measure  a  quick  sponging  with  water  at  from 
65°  to  70°  F.  (18.5°  to  21.5°  C.)  after  the  daily  bath  is  excellent. 

With  regard  to  drugs  it  may  be  stated  that  codliver  oil — which  is  a  food 
as  well  as  a  drug — is  our  chief  reliance.  It  may  be  given  in  doses  of  a  drachm 
(4.0)  or  less,  to  J  an  ounce  (15.0),  3  times  a  day  unless  it  disturbs  the  stomach 
when  it  should  be  administered  by  inunction  either  pure  or  mixed  with 
lanolin  in  the  proportion  of  i  to  3  or  4.  In  very  hot  weather  it  is  often  wise 
to  temporarily  discontinue  this  agent.  Phosphorus  has  been  much  used  in 
rhachitic  conditions  and  may  be  given  combined  with  olive  or  codliver  oil 
in  doses  of  yti7  to  y^iy  of  a  grain  (0.0003  to  0.0006)  3  times  a  day  after 
meals;  larger  doses  may  cause  digestive  disturbances.  The  following 
formula  is  a  useful  one:  phosphorus  5  grain  (0.008),  oil  of  sweet  almond  ^ 
ounce  (15.0),  acacia  2  drachms  (8.0),  syrup  2  drachms  (8.0),  distilled  water  to 
4  ounces  (120.0).  Dose,  i  teaspoonful  3  times  a  day  after  meals.  Lecithin 
may  be  substituted  for  phosphorus,  its  dosage  being  i  to  2  grains  (0.065 
to  0.13)  3  times  a  day  in  codliver  oil.  Calcium  has  been  prescribed  in  the 
hope  that  it  would  supply  the  lack  of  mineral  matter  in  the  bones  but  this 
hope  is  probably  vain  for  it  is  believed  that  any  lime  taken  into  the  organism 
in  excess  of  that  provided  by  the  food  is  excreted  through  the  alimentary 
tract.  Calcium,  however,  has  a  certain  tonic  effect  in  some  instances  and  may 
be  exhibited  as  the  following  formulae  suggest.  Calcium  phosphate  75  grains 
(5.0),  calcium  carbonate  2^  drachms  (lo.o),  milk  sugar  3I  drachms  (15.0), 
to  be  divided  into  30  powders  of  which  2  to  4  may  be  taken  daily.  Codliver 
oil,  lime  water  and  syrup  of  calcium  lactophosphate  equal  parts;  one  teaspoon- 
ful 3  times  a  day. 

Iron  in  the  form  of  the  syrup  of  the  iodide  may  be  prescribed  in  anaemic 
patients.     Arsenic  is  also  useful. 

Upon  the  theory  that  the  disease  is  the  result  of  a  disorder  of  the  thymus 
gland  the  administration  of  the  fresh  calf  thymus  in  dose  of  15  grains  (i.o) 
for  each  month  of  the  age  of  the  patient  has  been  suggested,  or,  if  desired, 


296  CONSTITUTIONAL    DISEASES. 

thymus  tablets  may  be  substituted  for  the  gland  substance.  Atropine  in 
doses  of  :5^i(T  of  a  grain  (0.000012)  for  a  child  of  i  year  will  lessen  the  tendency 
to  sweating. 

In  preventing  the  deformities  it  is  necessary  to  avoid  lifting  the  child  as 
much  as  possible  and  to  discourage  any  inclination  on  the  part  of  the  patient 
to  support  himself  in  the  standing  position;  he  should  not  be  allowed  even 
to  sit  up  unless  supported.  The  deformed  chest  may  be  brought  nearer  into 
normal  shape  by  ordering  systematic  respiratory  exercises  and  gymnastics, 
children  even  as  young  as  3  years  may  be  taught  simple  calisthenics,  and  the 
use  of  the  pneumatic  chamber  has  been  suggested.  The  tendency  to  spinal 
curvatures  may  be  lessened  by  keeping  the  patient  upon  a  hard  bed  without 
a  pillow  under  the  head,  but,  if  necessary,  a  thin  pad  under  the  lumbar  region, 
so  that  this  part  of  the  back  shall  be  raised  slightly  higher  than  the  shoulders 
and  buttocks.  Daily  placing  of  the  child  in  the  prone  position  and  over- 
correction of  the  deformity  by  lifting  the  buttocks,  the  lumbar  region  being 
held  stationary  meanwhile,  is  useful.  In  advanced  instances  orthopaedic  ap- 
paratus may  become  necessary.  The  curvatures  of  the  legs  may  be  corrected 
manually  and,  when  slight,  they  may  even  be  outgrown;  the  child  should  never 
be  allowed  to  sit  with  the  legs  crossed  beneath  him  or  habitually  in  any  position 
because  of  the  tendency  of  the  limbs  toward  deformity.  Braces  may  become 
necessary  but  any  treatment  of  this  sort  after  the  age  of  2^  years  is  usually 
futile  on  account  of  the  firmness  of  the  bones;  osteotomy  is  necessary  after 
this  period  but  should  usually  be  delayed  until  the  child  is  at  least  4  years 
old  and  the  bones  have  become  wholly  hardened.  Knock-knees,  bowlegs 
and  curvatures  of  the  radius  and  ulna  may  be  corrected  by  this  operation. 
The  flattened  pelvis  in  women  may  necessitate  Caesarean  section,  pubiotomy 
or  symphyseotomy  during  childbirth. 

In  the  management  of  rickets  it  is  necessary  to  remember  that  constitu- 
tional treatment  should  be  undertaken  as  early  as  possible  and  that  it  is  usually 
of  little  use  to  continue  it  after  the  beginning  of  the  i8th  or  20th  month,  for  by 
this  time  the  active  stage  of  the  disease  is  past  and  merely  the  results  of  the 
affection  remain. 


LEAD    POISONING.  297 


CHAPTER   III. 

THE  INTOXICATIONS,  INCLUDING  THE  EFFECTS  OF  EXPOSURE 
TO  HIGH  TEMPERATURES. 

LEAD  POISONING. 

Synonyms.     Plumbism;  Saturnism. 

Etiology.  This  is  a  common  condition  and  one  of  which  the  sources  are 
numerous.  The  most  important  are:  the  use  of  soft  water,  carbonated  waters 
and  alcoholic  drinks,  especially  beer,  which  have  passed  through  lead  pipes  or 
have  been  stored  in  receptacles  lined  with  lead;  the  occupations  of  painters 
{colica  pidonum),  plumbers,  typesetters,  gold  miners,  white  lead  workers, 
potters,  glaziers  (Devonshire  colic),  because  the  laborers  do  not  employ  ordinary 
cleanliness  and  neglect  to  wash  the  hands  before  eating;  the  use  of  lead  hair 
dyes  and  face  powders,  biting  leaded  white  thread,  eating  certain  canned  fruits 
(lead  solder),  sheet  lead  (tin  foil)  about  tobacco  or  sweets,  filling  holes  in  mill- 
stones with  lead,  playing  with  tin  (lead)  soldiers  by  children,  the  use  of  lead 
carbonate  on  burns,  of  diachylon  plaster  as  an  abortifacient  or  of  lead  and 
opium  pills  in  dysentery,  lead  bullets  in  the  flesh,  the  use  of  white  or  red  lead 
in  the  vulcanization  of  rubber,  false-tooth  plates  of  lead,  and  the  use  of 
baking  powder  adulterated  with  lead  chromate  to  give  buns  an  attractive 
yellow  color;  chronic  plumbism  has  been  attributed  to  all  these  factors. 

Lead  is,  perhaps,  the  best  example  of  a  poison  which  is  comparatively 
harmless  when  taken  in  a  single  large  dose,  but  of  which  most  minute  doses, 
if  taken  for  a  sufficient  period,  result  fatally. 

The  lead  enters  the  organism  through  the  skin,  respiratory  tract  or  the 
alimentary  system;  in  most  instances  of  poisoning  the  toxic  substance  has 
been  chiefly  taken  in  through  the  mouth.  Elimination  takes  place  through 
the  skin,  kidneys,  intestinal  tract,  saUva  and  milk. 

Pathology.  Normally  a  small  amount  of  lead  is  present  in  the  body  and 
it  is  not  very  unusual  for  minute  traces  of  the  metal  to  be  excreted  by  the 
urine.  In  plumbism  lead  is  demonstrable  in  the  organs  and  tissues.  The 
muscles  are  the  seat  of  fatty  and  fibrous  degeneration;  the  nerves  are  in  a 
state  of  degenerative  neuritis;  sometimes  fatty  changes  are  also  present.  The 
ganglion  cells  of  the  anterior  cornua  of  the  cord  may  be  in  a  condition  of 
atrophy  similar  to  that  found  in  anterior  poliomyeUtis.  In  acute  intoxica- 
tion the  lesions  of  intense  entero-colitis  mav  be  found. 


298  THE    INTOXICATIONS. 

Symptoms.  Acute  poisoning  is  most  frequently  due  to  taking  lead  acetate, 
a  very  large  amount  of  which  is  necessary  to  produce  a  fatal  effect,  particu- 
larly since  a  great  part  of  that  ingested  is  generally  vomited.  Gastro-intestinal 
symptoms  such  as  salivation,  thirst,  dysphagia,  abdominal  pain,  emesis  and 
diarrhoea  result  and  the  vomitus  consists  of  a  whitish  fluid  containing  curd- 
like matter;  in  consequence  of  the  astringency  of  the  lead  the  purging  is  less 
intense  than  that  caused  by  other  irritant  poisons,  constipation  being  some- 
times observed.  The  stools  may  be  blackish  owing  to  the  presence  of  lead 
sulphide  and  these  and  the  vomitus  may  contain  blood.  These  symptoms 
are  followed  by  weakness,  coldness  of  the  extremities  and  collapse.  After 
recovery  the  patient  may  suffer  from  chronic  plumbism. 

A  subacute  form  of  intoxication  is  sometimes  observed  in  which,  after  a 
short  exposure  to  the  effects  of  the  metal,  the  patient  suffers  from  anaemia, 
acute  neuritis  and  even  epileptiform  convulsions  and  delirium  similar  to  that 
caused  by  alcohol. 

Chronic  poisoning,  it  is  said,  may  sometimes  be  detected  by  painting  the 
skin  with  ammonium  sulphide  or  sodium  thiosulphate;  three  or  four  coats 
should  be  applied  to  a  patch  of  skin  several  inches  square  and  in  the  presence 
of  plumbism  this  area  will  turn  dark  in  about  24  hours  as  a  result  of  the 
formation  of  lead  sulphide.  The  presence  of  lead  is  also  demonstrable  in 
the  urine.  In  the  form  of  the  sulphide  lead  is  sometimes  deposited  upon  the 
edge  of  the  gums  producing  the  characteristic  "lead  line,"  this  is  black  in 
color  and  due  to  the  presence  of  hydrogen  sulphide  produced  by  the  action 
of  bacteria  (Burton's  sign) ;  if  the  teeth  are  sound  and  kept  clean  this  mani- 
festation is  usually  absent.  The  line  is  also  observed  in  some  instances  at  the 
junction  of  the  anal  mucous  membrane  with  the  skin. 

The  most  prominent  of  the  peripheral  nerve  effects  of  plumbism  is  lead 
colic,  a  phenomenon  which  is  due  to  violent  contraction  of  the  intestinal 
muscles,  probably  resulting  from  stimulation  of  the  nerve  endings.  As  it  is 
greatly  relieved  by  the  nitrites  and  other  vaso-dilators  it  may  be  inferred  that 
a  primary  vaso-constriction  is  one  of  its  causes.  With  the  colic  the  intestinal 
spasm  forces  the  blood  from  the  splanchnic  area  and  the  general  blood  pres- 
sure is  raised,  the  pulse  being  slowed  and  rendered  hard  and  tense.  The 
pain,  which  is  extreme  and  grinding  in  character,  is  chiefly  located  in  the 
umbilical  region,  and  the  abdomen  is  retracted  and  hard;  paroxysms  of  the 
most  acute  agony  are  often  succeeded  by  intervals  of  comparative  ease.  The 
colic  is  usually  preceded  by  constipation  and  may  be  accompanied  by  vomiting. 
The  paroxysms  may  last  for  several  days  or  a  week,  and  then  disappear  to 
recur  at  intervals. 

Other  nervous  symptoms  apparently  of  peripheral  origin  are  anaesthesia 
of  various  parts,  lasting  perhaps  one  or  two  weeks,  and  lead  arthralgia, 
which  consists  of  sharp  lancinating  or  boring  pain  in  the  joints,  bones,  or  the 


LEAD    POISONING.  299 

muscles  about  the  joints;  this  latter  usually  appears  and  disappears  quite 
suddenly,  the  wrist  may  be  swollen  (Gubler's  sign).  Neuralgias  are  some- 
times observed;  these  may  be  of  central  origin  or  due  to  peripheral  neuritis. 
Lead  amblyopia  is  a  rare  phenomenon;  the  sight  may  be  lost  entirely  or 
merely  somewhat  impaired.  This  manifestation  may  be  due  to  optic  neuritis, 
which,  if  allowed  to  continue,  leads  to  atrophy  of  the  nerve,  to  uraemia  with 
effusion  into  the  optic  sheath  or  to  albuminuric  retinitis. 

In  what  is  termed  encephalopathia  saturnalis  the  disorders  observed  are 
for  the  most  part  of  cerebral  origin,  although  the  lower  portions  of  the  central 
nervous  system  are  also  involved  at  times.  The  cortex  is  chiefly  affected 
and  an  irritation  is  produced  which  is  followed  by  paralyses,  both  sensory  and 
motor,  although  the  latter  are  the  more  pronounced.  There  are  usually 
muscular  contractures  and  later  choreic  movements.  Sometimes  convulsions 
occur  as  a  result  of  uraemia  due  to  the  nephritis  which  invariably  follows 
chronic  plumbism,  sometimes  they  are  due  to  the  lead  itself.  The  motor 
stimulation  is  ultimately  followed  by  paralysis.  In  addition  there  is  delirium, 
succeeded  by  depression  and  coma  which  latter  may  be  uraemic.  On  the 
motor  system  the  effects  produced  by  the  lead  are  neuritis,  paralysis  and 
atrophy.  The  usual  site  of  the  lesion  is  probably  in  the  peripheral  nerves 
and  muscle  cells,  though  in  certain  instances  the  central  nervous  system 
seems  to  be  involved.  A  common  characteristic  of  lead  poisoning  is  the 
''^ drop-wrist'^  or  ^''painter's  palsy,'''  which  is  probably  attributable  in  part 
to  paralysis  of  the  extensor  muscles  and  partly  to  the  active  contracture  of 
the  opposing  flexors.  A  characteristic  of  lead  palsy  is  that  the  supinator 
longus  is  not  involved  and  the  electrical  response  of  the  affected  muscles  is 
less  than  in  other  types  of  peripheral  neuritis. 

The  patient  afflicted  with  chronic  plumbism  is  always  anaemic;  this  con- 
dition of  the  blood  is  at  first  due  to  the  constriction  of  the  peripheral  vessels 
and  later  to  diminution  of  the  haemoglobin  and  red  corpuscles  in  the  blood. 
There  is  granular  basophilic  degeneration  in  many  of  the  red  cells  and  the 
presence  of  this  condition  is  of  some  diagnostic  value.  Nucleated  red  cells 
are  often  found  even  if  the  anaemia  is  not  of  severe  grade.  Jaundice  may 
result  from  the  breaking  up  of  red  corpuscles  and  the  liberation  of  large 
amounts  of  haemoglobin.     The  leucocytes  are  often  increased  in  number. 

The  results  of  lead  intoxication  upon  the  circulatory  system  consist  in  the 
production  of  arteriosclerosis  which  is  early  evidenced  by  a  high  tension  of 
the  pulse  and  an  accentuation  of  the  2d  aortic  sound.  These  manifestations 
may  be  demonstrable  before  either  colic  or  palsy  is  observed.  Cardiac  hyper- 
trophy is  common  and  the  wall  of  the  organ  may  be  in  a  state  of  fatty  or 
fibrous  degeneration. 

In  the  kidneys  lead  causes  marked  irritation  in  the  process  of  its  elimi- 
nation, consequently  nephritis  is  frequent  in  instances  of  acute  poisoning 


300 


THE    INTOXICATIONS. 


and  is  uniformly  found  in  chronic  plumbism  both  as  a  result  of  this  irritation 
and  of  the  arteriosclerosis  induced  by  the  presence  of  lead  in  the  organism. 

A  remarkable  circumstance  in  connection  with  lead  poisoning  is  the  fre- 
quency of  gout  in  its  subjects;  this  coincidence  is  much  more  common  in 
England  than  in  America.  In  districts  where  the  ordinary  type  of  gout  is 
rare  it  is  said  that  the  disease  is  seldom  induced  by  lead. 

The  prognosis  depends  upon  the  degree  of  the  intoxication;  it  is  favorable 
in  early  instances.  Atrophic  paralysis  is  likely  to  prove  difficult  of  cure  and 
the  mental  symptoms  of  lead  encephalopathy  may  be  permanent.  The  arterial 
lesions  and  those  of  the  viscera  which  are  evidenced  by  degenerative  changes 
are  usually  incurable. 

Treatment.  Prophylaxis  is  of  the  greatest  importance  and  the  public 
should  be  more  fully  instructed  concerning  the  dangers  of  lead.  Special 
precautions  are  required  in  lead  works,  paint  factories  and  in  exposed  trades. 
Dust  should  be  avoided  as  much  as  possible,  and,  where  this  is  necessarily 
present,  thorough  ventilation  is  an  absolute  essential.  The  necessity  of  fre- 
quent bathing  and  thorough  washing  before  eating  cannot  be  too  strongly  im- 
pressed upon  the  workman.  The  addition  to  the  bath  of  sodium  hypochlorite 
or  potassa  sulphurata  has  been  suggested  upon  the  ground  that  the  sulphur 
neutralizes  the  lead  by  forming  insoluble  compounds  with  it.  Food  should 
not  be  permitted  upon  the  premises  and  the  clothing  should  be  changed  before 
leaving  the  works.  The  systematic  use  of  milk  in  large  amounts  as  a  food 
is  to  be  recommended.  Sulphuric  acid  lemonade  is  generally  employed  as  a 
prophylactic  but  is  not  particularly  reliable.  "Weak  or  anaemic  individuals 
should  not  be  employed  as  workers  in  lead  and  it  is  advisable  that  women 
should  be  altogether  excluded  from  such  occupations. 

In  treatment  the  first  indication  is  to  remove  the  patient  from  the  danger 
of  further  poisoning.  In  general,  reliance  is  placed  upon  potassium  iodide, 
saline  purgatives,  diuretics  and  the  use  of  hot  baths  and  massage  to  promote 
elimination,  and  upon  the  employment  of  appropriate  measures  to  improve 
the  patient's  nutrition  and  strength.  Potassium  iodide  is  in  universal  use 
and  appears  to  have  a  beneficial  effect  though  the  manner  of  its  action  is 
not  clearly  understood.  It  has  been  supposed  to  accelerate  elimination 
through  the  kidneys,  but  it  has  recently  been  denied  that  the  drug  has  any 
influence  upon  excretion  by  the  urine  or  by  the  intestinal  tract  through  which 
most  of  the  lead  escapes  from  the  body.  Baths  of  sulphurated  potassium  are 
efficient,  especially  if  the  patient  is  well  soaped  afterward  and  then  thoroughly 
rinsed  and  rubbed  with  a  rough  towel.  For  the  colic  opium  or  morphine 
is  often  necessary,  alum  in  2  girain  (0.13)  doses  is  of  great  service  and  dilute 
sulphuric  acid  is  also  useful.  The  constipation  may  be  relieved  by  a  combi- 
nation of  magnesium  sulphate  and  dilute  sulphuric  acid  and  the  lead  cachexia 
is  greatly  benefited  by  the  latter,  given  in  connection  with  quinine  and  ferrous 


ARSENICAL    POISONING.  30I 

sulphate.  In  certain  instances  of  chronic  plumbism  cathartics  fail  to  act 
unless  morphine  is  given  to  overcome  the  intestinal  inhibition  produced  by 
the  irritation  resulting  from  the  lead.  Opiates  may  also  be  required  for  the 
relief  of  the  joint  pains.  For  the  paralyses  strychnine  may  be  administered 
but  our  chief  reliance  is  placed  upon  electricity  and  massage  (see  the  section 
upon  the  treatment  of  multiple  neuritis).  If  the  muscles  contract  in  response 
to  the  faradic  current  this  should  be  employed,  but  if  not  the  galvanic  current 
should  be  used.  Nephritis  and  gout  due  to  lead  intoxication  should  be  treated 
in  the  same  way  as  when  resulting  from  other  causes  and  the  cerebral  symp- 
toms must  be  dealt  with  according  to  the  special  manifestations  which  present 
themselves. 

ARSENICAL  POISONING. 

Acute  arsenic  poisoning  as  a  result  of  the  ingestion  of  Paris  green,  or  of 
one  of  the  various  rat  or  vermin  poisons  which  contain  this  substance  (cupric 
arsenite),  is  common. 

Symptoms.  These  as  well  as  the  pathology  of  the  condition  closely 
resemble  those  of  Asiatic  cholera.  Large  doses  often  cause  no  distress  for 
a  considerable  period,  but,  within  a  half  hour  or  perhaps  longer,  the  patient 
experiences  dysphagia  with  a  sense  of  faucial  constriction.  Epigastric  pain, 
quickly  becoming  extreme  and  general  over  the  abdomen,  follows;  with  it 
are  associated  nausea  and  excessive  emesis  and  later  there  is  profuse  watery 
diarrhoea  with  tenesmus  and  thirst.  The  vomitus  and  stools  may  contain 
blood  and  there  are  muscular  cramps,  headache  and  dizziness;  collapse 
ensues,  with  coldness  of  the  extremities,  pallor,  small,  feeble  pulse  and  sighing 
respiration.  Coma  follows,  and  death,  sometimes  preceded  by  convulsions, 
takes  place.  Rarely  the  only  symptoms  noted  have  been  collapse  and  coma. 
Death  may  occur  within  24  hours  but  usually  the  patient  lingers  for  several 
days.  If  recovery  takes  place  the  symptoms  of  chronic  arsenic  poisoning 
may  develop. 

Treatment  consists  in  immediately  emptying  the  stomach  by  lavage  or  by 
emetics  such  as  zinc  sulphate,  20  to  30  grains  (1.33  to  2.0)  or  a  tablespoonful 
of  mustard  to  a  tumbler  of  warm  water.  After  the  gastric  contents  have 
been  removed  the  organ  should  be  repeatedly  washed  with  warm  water  on 
occount  of  the  insolubility  of  the  arsenic.  At  the  same  time  large  amoimts 
of  freshly  prepared  ferric  hydroxide  with  magnesium  oxide  or  dialyzed  iron, 
one  ounce  (30.0)  should  be  given.  The  former  mixture  may  be  prepared 
by  using  150  grains  (10. o)  of  magnesium  oxide  to  which  is  added  sufficient 
water  to  make  a  thin  magma  which  is  slowly  poured  into  a  solution  consisting 
of  ferric  sulphate.  10  drachms  (40.0)  and  water,  4  ounces  (120.0);  the  product 
is  then  shaken  until  a  smooth  mixture  results.     If  either  of  these  antidotes  is 


302 


THE    INTOXICATIONS. 


unobtainable  light  magnesia  mixed  with  water  may  be  substituted.  The 
antidote  must  be  repeated  at  intervals  as  long  as  acute  symptoms  persist.  If 
neither  magnesia  nor  the  iron  preparations  are  available,  dependence  may 
be  placed  upon  large  doses  of  castor  oil  and  water.  The  collapse  should 
be  combated  by  means  of  subcutaneous  injections  of  brandy  or  aether  and  warm 
applications  should  be  made  to  the  abdomen  and  extremities. 

Chronic  Poisoning.  The  medicinal  administration  of  arsenic  in  too  large 
doses  may  induce  slight  toxic  symptoms  such  as  abdominal  pain,  anorexia, 
nausea,  indigestion,  mild  diarrhoea,  puffiness  of  the  eyelids,  conjunctival 
injection  and  watering  of  the  nose  and  eyes.  Cutaneous  eruptions  are  some- 
times caused,  and,  while  these  may  be  in  part  a  result  of  circulatory  disorders, 
they  are  believed  to  be  due  chiefly  to  a  direct  action  of  the  drug  upon  the  skin. 
They  may  be  erythematous,  papular,  vesicular  or  pustular  and  may  be  asso- 
ciated with  a  swelling  resembling  that  of  erysipelas.  Prolonged  administration 
of  arsenic,  it  is  said,  may  cause  herpes  zoster. 

Arsenic  is  extensively  used  in  the  arts,  especially  in  the  manufacture  of 
wall  papers  and  fabrics,  and  consequently  accidental  poisoning  among  workers 
in  arsenic  is  not  rare;  it  may  also  occur  in  individuals  who  use  articles  con- 
taining the  drug.  The  evidence  regarding  chronic  poisoning  from  occupancy 
of  rooms  decorated  with  arsenical  wall  papers  is  contradictory  but  the  facts 
favor  its  probability.  Quite  as  often  the  poisoning  is  due  to  the  arsenic  which 
contaminates  anihne  dyes  as  it  is  to  arsenical  pigments,  consequently  chemi- 
cal examination  should  be  depended  upon  rather  than  color.  Epidemic 
arsenic  poisoning  has  occurred  from  the  use  of  beer  in  the  manufacture  of 
which  contaminated  glucose  has  been  employed. 

Symptoms.  In  addition  to  the  manifestations  mentioned  above,  chronic 
arsenic  poisoning  is  evidenced  by  a  catarrhal  condition  of  the  nasal  and 
pharyngeal  mucous  membranes,  with  sneezing  and  coughing;  the  various 
cutaneous  eruptions  appear  and  in  some  instances  there  is  a  pigmentation 
of  the  skin  (arsenic  melanosis);  eventually  the  hair  and  nails  fall.  Enlarge- 
ment of  the  liver  with  jaundice  is  sometimes  observed  and  the  later  phases 
of  the  disorder  are  characterized  by  localized  sensory  and  motor  disturbances, 
chiefly  in  the  hands  and  feet,  resulting  from  polyneuritis.  There  are  acute 
pain  and  sensations  of  formication  in  the  extremities,  followed  by  sensory 
paralyses  with  symptoms  analogous  to  those  of  locomotor  ataxia.  These 
symptoms  are  followed  by  motor  paralysis,  as  a  rule  confined  to  the  limbs, 
but  in  some  instances  involving  the  trunk.  The  paralysis  is  usually  symmet- 
rical and  the  affected  muscles^  which  are  more  often  those  of  the  extensor 
than  flexor  groups,  become  atrophied.  Herpes  zoster  of  the  face  or  trunk  is 
common.  In  very  protracted  instances  the  patient  may  sink  into  an  apathetic 
semi-idiotic  state  or  epilepsy  may  supervene.  After  death,,  in  addition  to 
the  lesions  in  the  digestive  organs  and  nervous  system,  a  condition  of  fatty 


MERCURIAL    POISONING.  303 

degeneration  of  the  viscera,  especially  the  liver,  kidneys,  stomach  and  heart, 
as  well  as  of  the  muscles,  is  found. 

A  more  full  discussion  of  the  nervous  symptoms  of  chronic  arsenical  poison- 
ing will  be  found  in  the  section  upon  multiple  peripheral  neuritis. 

Treatment  consists  in  the  discontinuance  of  arsenic  if  this  is  being  admin- 
istered, or  if  the  condition  is  the  result  of  arsenical  surroundings,  a  removal 
from  exposure.  Elimination  of  the  drug  should  be  accelerated  by  means 
of  laxatives,  diuretics,  diaphoretics,  and  the  administration  of  potassium 
iodide.  The  treatment  is  otherwise  symptomatic;  the  management  of  the 
paralyses  will  be  discussed  under  the  treatment  of  multiple  peripheral  neuritis. 
Tonics  and  plenty  of  nourishing  and  easily  digestible  food  are  indicated. 
Recovery  usually  takes  place. 

MERCURIAL  POISONING. 

Synonym.     MercuriaHsm. 

Acute  mercury  poisoning  from  corrosive  sublimate  or  white  precipitate 
is  not  unusual.  Mercury  bichloride  in  toxic  dosage  at  once  causes  a  metallic 
taste  in  the  mouth,  extreme  pain  in  the  pharynx  and  stomach,  rapidly  followed 
by  intense  retching  and  emesis.  The  vomitus  soon  becomes  bloody  and 
violent  purging  occurs,  the  stools  being  at  first  serous  in  character,  later 
haemorrhagic.  The  urine  becomes  scanty  and  contains  albumin,  casts  and 
blood;  the  pulse  becomes  weak  and  rapid,  the  temperature  falls  below  normal, 
all  the  vital  energies  are  depressed  and  death  may  take  place  within  a  short 
time. 

The  post  mortem  lesions  are  usually  those  of  a  membranous  colitis  and  a 
parenchymatous  and  haemorrhagic  nephritis,  with  general  degeneration  of 
the  tubal  epithelium;  more  rarely  there  is  a  peculiar  deposit  of  calcium  phos- 
phate. 

Treatment.  The  stomach  should,  if  possible,  be  emptied  immediately  by 
means  of  the  stomach  tube,  or,  if  this  is  not  at  hand,  emesis  should  be  provoked 
by  faucial  irritation,  draughts  of  mustard  and  warm  water  or  by  the  hypo- 
dermatic injection  of  apomorphine  hydrochloride  in  dose  of  yV  of  a  grain 
(0.006).  Albumin  in  the  form  of  the  white  of  egg,  that  of  one  being  sufficient 
antidote  for  4  grains  (0.24)  of  corrosive  sublimate,  the  albuminate  redis- 
solving  in  an  excess,  or  milk  and  flour  should  be  given.  Tannic  acid  is  also 
useful  since  it  protects  the  mucous  membranes  of  the  gastro-intestinal  tract 
from  the  action  of  the  drug. 

Chronic  mercury  poisoning  is  less  frequently  observed  than  formerly 
when  the  administration  of  large  doses  of  the  drug  was  common.  Workers 
in  the  metal  are  sometimes  affected,  the  most  profound  instances  of  intoxi- 
cation being  due  to  the  prolonged  exposure  to  its  fumes. 


304  THE    INTOXICATIONS. 

Symptoms.  The  first  evidences  of  mercurialism  are  referable  to  the  mouth. 
At  first  there  is  sHght  foetor  of  the  breath,  later  an  unpleasant  metallic  taste 
and  tenderness  of  the  teeth  when  they  are  forcibly  brought  together  are  noted. 
These  are  followed  by  stomatitis,  sponginess  of  the  gums  and  salivation. 
If  the  ingestion  of  the  mercury  is  continued  the  amount  of  saliva  secreted 
becomes  enormous;  it  is  irritant  and  contains  mercury.  The  breath  becomes 
very  foul,  the  gums  are  intensely  inflamed,  bleed  at  the  lightest  touch  and 
are  marked  at  the  junction  of  the  teeth  by  a  dark  red  line.  The  teeth  are 
loosened  and  may  fall,  the  tongue  and  lips  become  involved  in  an  obstinate 
inflammation  which  proceeds  to  ulceration,  and,  extending  as  gangrene  to 
the  cheeks,  may  produce  frightful  facial  deformity.  Even  the  maxillary 
bones  may  undergo  necrosis.  Nervous  symptoms,  such  as  tremors,  erythism, 
and  hallucinations,  may  appear  and  the  faculties  may  be  dulled.  There  is 
general  muscular  weakness  and  paralysis,  with  areas  of  partial  anaesthesia, 
and  joint  pains  may  occur.  The  peripheral  neuritis  of  chronic  mercurialism 
is  a  much  later  manifestation  than  that  of  plumbism  and  even  after  the  develop- 
ment of  the  palsies  the  muscles  retain  their  irritability  and  do  not  undergo 
atrophy.  The  reflexes  are  usually  unaffected;  rarely  they  may  be  exag- 
gerated. General  nutrition  is  impaired  and  metabolism  is  profoundly  affected, 
anaemia  and  marked  cachexia  resulting.  With  the  cachexia  the  heart  becomes 
weakened,  the  respiration  rapid  and  shallow  and  the  mentality  impaired; 
the  memory  is  imperfect,  the  temper  irritable  and  melancholia  and  even 
mania  may  ensue.  The  special  senses  are  affected  as  evidenced  by  deafness, 
dimness  of  sight  and  impairment  of  taste  and  sensation. 

Treatment  consists  in  acceleration  of  the  elimination  of  the  mercury  through 
all  possible  channels.  Elimination  through  the  skin  is  favored  by  baths  of 
sulphur  and  ordinary  hot  water  and  diuresis  should  be  induced  by  causing 
the  patient  to  drink  as  much  water  as  can  conveniently  be  borne  and  by  the 
administration  of  diuretic  drugs.  Free  evacuation  of  the  bowels  is  necessary 
but  if  marked  diarrhoea  is  present  it  may  call  for  treatment  by  means  of  opiates 
and  other  remedies.  The  pain  may  necessitate  the  employment  of  opium. 
The  common  belief  that  potassium  and  sodium  iodides  have  an  effect  in 
causing  the  elimination  of  the  metal  has  been  disputed  but  never  disproven; 
at  any  rate  the  proper  administration  of  these  drugs  can  do  no  harm;  care, 
however,  should  be  taken  that  the  doses  are  not  too  large,  for  the  combination 
of  iodine  with  mercury  in  the  tissues  produces  a  soluble  salt  which  is  very 
active  and  may,  at  times,  cause  secondary  systemic  mercurial  poisoning. 
Belladonna  is  sometimes  required  to  diminish  the  excessive  secretion  of  saliva 
and  in  all  instances  a  mouth  wash  of  potassium  chlorate  solution  is  useful  in 
the  relief  of  the  salivation  and  stomatitis;  tincture  of  myrrh  may  be  added 
to  it  and  a  mouth  wash  of  tannic  acid  may  also  be  employed.  Careful  atten- 
tion should  be  given  to  the  general  hygiene  and  the  cachexia  should  be  com- 


ANTIMONIAL    POISONING.  305 

bated  by  plenty  of  nutritious  food  and  such  tonic  and  other  remedies  as  may 
be  indicated.  The  treatment  in  other  regards  is  symptomatic;  for  the  neuritis 
the  methods  and  means  of  treatment  suggested  in  the  section  upon  multiple 
peripheral  neuritis  should  be  employed.  Prophylactic  means  such  as  those 
indicated  in  the  prevention  of  plumbism  should  be  recommended  in  estab- 
lishments where  mercury  is  used. 


ANTIMONIAL  POISONING. 

Acute  antimonial  poisoning  resembles  in  its  symptoms  acute  arsenical 
intoxication,  the  chief  manifestations  being  those  of  intensely  acute  gastro- 
intestinal irritation.  At  autopsy  the  mucous  membrane  of  the  stomach  and 
intestine  is  found  in  a  state  of  h}^ersemia  and  tumefaction;  erosions  and 
ecchymoses  are  usually  present.  There  are  often  pustules  in  the  mouth, 
oesophagus,  stomach  and  small  intestine  and  pulmonary  congestion  or  inflam- 
mation may  be  demonstrable. 

Treatment.  The  vomiting  caused  by  the  drug  itself  usually  obviates  the  neces- 
sity for  the  employment  of  emetics  but,  if  free  emesis  has  not  taken  place,  gastric 
lavage  is  indicated  or  apomorphine  hydrochloride,  y  o'  of  a  grain  (0.006)  hypo- 
dermatically  or  zinc  sulphate,  20  to  30  grains  (1.33  to  2.0)  by  mouth  should  be 
administered.  The  bowels  should  be  cleared  of  the  poison  in  this  situation 
by  a  purge.  The  antimony  in  the  stomach  may  be  precipitated  by  tannic 
acid  in  doses  of  30  grains  (2.0);  the  tannate  thus  formed  should  be  washed 
out.  If  the  acid  is  unobtainable  a  strong  infusion  of  hot  tea  may  be  substi- 
tuted. The  gastric  irritation  may  be  alleviated  by  mucilaginous  drinks 
and  milk.  The  cardiac  depression  should  be  combated  by  means  of  hypoder- 
matic injections  of  alcohol,  aether  or  strychnine  and  hot  applications  to  the 
abdomen  and  extremities  are  indicated. 

Chronic  antimony  poisoning  is  of  rare  occurrence  and  difficult  of  diagnosis, 
the  symptoms  being  of  indefinite  character.  They  consist  of  headache, 
vertigo,  depression,  impaired  vision,  nausea,  vomiting,  gastric  disturbance 
with  pain,  diarrhoea,  albuminuria,  emaciation,  weakness,  exhaustion  and 
ultimate  collapse.  The  resemblance  of  the  symptoms  to  those  of  catarrhal 
gastro-enteritis  renders  the  diagnosis  of  chronic  antimony  intoxication,  when 
the  drug  is  given  with  homicidal  intent,  very  difficult. 

After  death  antimony  is  said  to  be  found  in  the  liver,  spleen,  kidneys,  bones 
and  muscles;  fatty  degeneration  of  the  viscera  is  also  observed.  The  pro- 
tracted administration  of  tartar  emetic  is  stated  to  produce  pustular  erup- 
tions. 

Treatment  consists  in  stopping  the  drug  and  in  the  employment  of  symp- 
tomatic and  stimulative  measures. 


3o6  THE    INTOXICATIONS. 

lODISM. 

lodism,  the  term  applied  to  the  train  of  symptoms  resulting  from  the  pro- 
longed administration  of  the  iodides,  is  induced  by  all  these  salts;  the  basic 
ion  does  not  appear  to  be  concerned  in  the  effect  produced.  Owing  to  the 
fa.ct  that  iodine  is  more  readily  freed  from  it,  ammonium  iodide  is  said  to  be 
more  likely  to  cause  iodism  than  the  other  salts. 

Symptoms.  These  may  be  separated  into  two  groups,  (i)  Frequently 
there  is  catarrh  of  the  respiratory  passages  which  commences  in  the  nasal 
mucous  membrane  and  is  evidenced  by  a  profuse  watery  discharge;  the  inflam- 
mation extends  upward  and  downward  producing  conjunctivitis  and  perhaps 
severe  headache  due  to  involvement  of  the  frontal  sinuses.  Accompanying 
this  there  is  faucial  swelling  and  irritation,  the  tonsils  may  become  inflamed, 
and  laryngitis  and  bronchitis  may  result.  Laryngeal  oedema  may  occur  and 
cause  death  unless  relieved.  Somewhat  later  an  eruption  may  appear,  con- 
sisting of  erythematous  patches  or  papules  which  may  become  pustular; 
other  eruptions  have  been  observed.  CEdema  of  the  face  is  met  in  some 
instances  and  there  may  be  albuminuria.  Nervous  manifestations  such  as 
neuralgia,  tinnitus  aurium,  con\ailsive  movements,  disturbed  intellection 
and,  rarely,  atrophy  of  the  mammas  and  testes,  have  been  described.  (2) 
Iodic  cachexia,  in  which  rapid  emaciation  takes  place,  is  a  late  phenomenon 
and  intense  cardiac  palpitation  and  ravenous  appetite  may  develop. 

The  local  manifestations  of  iodism  can  sometimes  be  prevented  by  the 
administration  of  alkalies  and  hence  it  is  thought  that  the  variation  of  their 
extent  in  different  individuals,  or  in  the  same  person  at  different  times,  may 
be  explained  by  a  varying  degree  of  acidity.  A  tolerance  may  be  established 
and  sometimes  the  symptoms  disappear  while  the  drug  is  still  being  taken. 
Even  though  the  manifestations  may  be  intense  they  usually  cease  soon  after 
treatment  is  discontinued  and  the  chewing  of  pellitory  will  hasten  the  elimi- 
nation of  iodine  in  the  chronic  forms.  When  iodic  cachexia  has  occurred 
the  symptoms  may  not  disappear  for  a  considerable  time. 

BROMISM. 

This  term  has  been  given  to  the  toxic  symptoms  resulting  from  the  pro- 
longed administration  of  the  bromides.  The  condition  is  rarely  caused  by 
hydrobromic  acid  although  this  substance  contains  a -relatively  large  propor- 
tion of  bromine. 

Symptoms.  The  first  of  these  is  usually  a  papular  acneiform  eruption 
appearing  chiefly  upon  the  face  and  back.  In  marked  instances  the  papules 
become  pustules  which  may  coalesce,  forming  small  abscesses  which  at  times 
become  ulcers.  At  other  times  the  rash  resembles  eczema  and  sometimes 
there  is  an  erythema  or  a  brown  pigmentation  of  the  skin.     The  tongue  is 


BORISM.  307 

coated  and  there  are  digestive  disturbances;  frequently  there  is  a  coryza  which 
may  be  associated  with  increased  bronchial  secretion  and  mild  conjunctivitis. 
These  manifestations  are  attributed  to  a  local  irritant  action  partly  due  to 
the  salt  action  of  the  bromine  salt  and  partly  to  decomposition  of  the  bromide, 
with  liberation  of  bromic  acid  and  bromine  by  the  free  acids  in  different  situa- 
tions, as  hydrochloric  acid  in  the  stomach,  carbon  dioxide  in  the  air  passages, 
etc.  This  action  takes  place  more  readily  in  old  age  and  if  renal  insufficiency 
is  present.  From  the  influence  of  the  drug  on  the  nervous  system  the  cuta- 
neous sensibility  and  the  sensitiveness  of  the  faucial  mucous  membrane  are 
distinctly  reduced  while  the  sexual  desire  becomes  diminished.  There  is 
indisposition  on  the  part  of  the  patient  to  any  exertion,  he  is  easily  fatigued, 
his  gait  is  uncertain  and  there  is  often  marked  muscular  tremor.  The  intel- 
lect is  dulled  and  the  memory  impaired,  the  patient  takes  Httle  interest  in 
his  surroundings,  his  speech  is  slow  and  he  may  stammer,  mispronouncing 
words  or  omitting  several  from  a  spoken  sentence.  The  facies  is  apathetic 
and  stupid  and  the  eyes  are  heavy  and  without  lustre.  Mental  excitement, 
confusion  and  sometimes  delirium  may  follow  the  continued  use  of  moderate 
doses,  especially  of  the  potassium  salt.  The  habitual  user  of  bromides  is 
unable  to  sleep  without  them,  and  a  gradual  increase  of  the  dose  is  required 
to  induce  slumber,  consequently  the  systemic  effects  are  usually  disastrous. 
In  addition  the  patient's  powers  of  resistance  to  disease  are  lowered  and  inter- 
current affections,  such  as  pneumonia  or  even  bronchitis,  may  result  in  death. 
Notwithstanding  the  severity  of  the  symptoms  of  bromism,  they  soon  dis- 
appear after  the  withdrawal  of  the  drug  and  its  elimination  from  the  system. 
Treatment  consists  in  stopping  the  administration  of  the  bromides  and  in 
the  employment  of  measures  calculated  to  relieve  the  symptoms  and  to  support 
the  patient. 

BORISM. 

The  continued  internal  use  of  too  large  amounts  of  boric  acid  or  borax 
(sodium  biborate)  results  in  a  train  of  symptoms  which  has  been  denominated 
borism.  In  some  instances  even  moderate  doses  of  these  substances  have  a 
mild  aperient  action  while  in  large  amounts  they  are  gastro-intestinal  irri- 
tants and  cause  emesis  and  purging.  Other  symptoms  produced  by  toxic- 
quantities  are  dryness  of  the  pharynx  and  dysphagia,  intense  muscular  weak- 
ness, pain  in  the  back  and  vesical  tenesmus  with  albuminuria  and  sometimes 
haematuria,  impairment  of  sight,  headache,  insomnia  and  nervous  depres- 
sion, which  may  be  followed  by  fatal  collapse.  A  rise  of  temperature  is  fre- 
quently observed  and  in  2  or  3  days,  if  death  does  not  supervene,  scaly, 
papular  or  eczematous  eruptions  appear  upon  the  skin.  The  symptoms 
are  evidenced  more  rapidly  when  the  drugs  are  taken  by  mouth  but  mani- 
festations of  the  same  character  may  result  from  their  free  application  in  the 


3o8  THE    INTOXICATIONS. 

rectum,  vagina  or  other  parts.  Boric  acid  and  borax  are  rapidly  absorbed  from 
the  mucous  membranes  and  from  abrasions,  and  serious  instances  of  poisoning 
have  been  reported  as  due  to  the  use  of  the  acid  as  an  antiseptic  dressing. 

In  chronic  poisoning  the  symptoms  are  often  very  similar  to  those  of  acute 
intoxication,  the  cutaneous  manifestations  are,  however,  more  prominent  and 
may  constitute  the  only  positive  evidence  of  toxic  effect,  although  there  are  usu- 
ally indications  of  more  or  less  gastro-intestinal  and  renal  irritation.  CEdema 
of  the  face  and  extremities  may  occur  as  a  result  of  the  latter,  and  consequently 
it  is  advisable  to  keep  a  careful  watch  of  the  condition  of  the  urine  whenever 
these  drugs  are  administered.  The  hair  often  becomes  dry  and  falls,  and 
the  eruption  upon  the  skin  may  resemble  a  seborrhoeic  eczema,  appearing 
as  reddish  patches  which  desquamate  like  psoriasis,  or  papules  attended 
with  marked  pruritus.  The  most  common  eruption  is  said  to  be  scaly,  assum- 
ing the  form  of  a  seborrhoeic  dermatitis,  but  usually  associated  with  much 
more  oedema.  Sometimes  the  skin  and  mucous  membranes  are  dry,  the 
lips  become  fissured,  the  nails  are  striated  and  a  blue  line  similar  to  that  of 
plumbism  may  appear  upon  the  gums.  The  question  of  the  effect  of  the  con- 
tinued and  habitual  introduction  into  the  organism  of  boric  acid  or  borax 
as  employed  in  the  preservation  of  food,  is  of  considerable  interest.  The 
results  of  careful  experimentation  conducted  by  the  Bureau  of  Chemistry, 
United  States  Department  of  Agriculture,  show,  on  the  whole,  that  7^  grains 
(0.5)  daily  is  too  much  for  a  normal  man  to  receive  regularly;  on  the  other 
hand  a  normal  individual  may  take  this  quantity  of  boric  acid  or  borax,  ex- 
pressed in  terms  of  boric  acid,  for  a  limited  period  of  time  with  slight  danger 
of  injuring  the  health.  The  chief  objection  to  the  employment  of  these  sub- 
stances as  food  preservatives  seems  to  rest  upon  the  fraud  in  permitting  inferior 
goods  to  be  marketed  as  high  class  products.  This  applies  especially  to 
meats  and  milk  although  the  addition  of  small  quantities  of  these  substances 
may  be  beneficial  since  it  delays  the  souring  of  the  latter.  If  larger  amounts 
are  used  with  fraudulent  intent,  the  milk  is  apt  to  be  kept  too  long,  to  be 
of  poor  quality  and  the  quantity  of  the  preservative  may  be  sufficient  to 
injure  infants  who  take  the  milk  as  a  routine. 

Treatment  consists  in  stopping  the  ingestion  of  the  adulterated  food  stuffs 
•and  the  employment  of  means  calculated  to  relieve  the  existing  symptoms. 

ALCOHOLISM. 

Acute  Alcoholism. 

Definition.  The  result  of  the  imbibition  of  a  considerable  amount  of 
alcohol  in  any  of  its  forms  and  within  a  short  space  of  time.  The  quantity 
necessary  to  produce  drunkenness  varies  greatly  with  the  individual. 


ALCOHOLISM.  309 

Symptoms.  These  are  chiefly  referable  to  the  nervous  system  and,  while 
the  sequence  of  their  appearance  is  not  constant,  there  is  usually  a  primary 
stage  of  excitation  during  which  the  subject's  face  becomes  flushed,  his  eyes 
brightened  and  his  tongue  garrulous;  the  speech  is  at  first  coherent  but  soon 
becomes  senseless;  muscular  coordination  is  disturbed  as  evidenced  by  the 
staggering  gait.  Locomotion  soon  becomes  impossible  and  finally  alcoholic 
coma  supervenes.  Other  individuals  are  differently  affected;  instead  of  the 
primary  excitement  being  evidenced  by  joUity  and  good  nature  it  may  be 
characterized  by  moroseness  and  the  subject  may  be  incited  to  violence  and 
even  murder  by  very  slight  provocation.  The  stage  of  narcosis,  however, 
ultimately  ensues  as  in  the  previously  described  type  of  alcoholism,  if  suffi- 
cient liquor  is  taken. 

Alcoholic  coma  is  not  always  easy  of  diagnosis.  The  face  is  usually  flushed 
but  may  present  a  cyanotic  appearance,  the  pulse  is  strong  and  full,  respira- 
tion is  deep,  slow  and  sometimes  stertorous.  The  temperature  may  be 
subnormal,  at  times  even  below  90°  F.  (32.2°  C).  The  urine  and  faeces 
may  be  passed  involuntarily,  the  pupils  are  dilated  and  muscular  twitchings 
may  be  present.  The  individual  may  be  temporarily  aroused  in  most  instances 
by  pressing  upon  the  upper  margin  of  the  orbits  at  the  junction  of  their  inner 
and  middle  thirds — the  points  of  emergence  of  the  supra-orbital  nerves. 
There  is  usually  an  odor  of  alcohol  upon  the  breath.  One  of  the  most  common 
of  the  mistakes  to  which  the  young  ambulance  surgeon  is  liable  is  the  con- 
founding of  basilar  fractures  of  the  skull  for  alcoholism.  This  mistake  is 
rendered  a  particularly  easy  one  by  the  frequence  with  which  the  two  condi- 
tions co-exist.  In  fracture  the  coma  is  usually  deeper,  the  respiration  stertor- 
ous and  the  pupils  are  often  unequal.  Bleeding  from  mouth,  nose  or  ears  is 
very  characteristic.  The  difficulty  of  differentiation  is  often  so  great  that  it  is 
always  the  part  of  wisdom  to  give  the  patient  the  benefit  of  every  doubt  and 
to  consider  all  dubious  instances  of  coma  as  proper  for  admission  to  a 
hospital. 

Cerebral  apoplexy  may  be  separated  from  alcoholic  coma  by  its  deeper 
unconsciousness,  pupillary  inequality,  the  evidences  of  cardiac  or  vascular 
disease  or  of  partial  paralysis. 

In  urczmic  coma  the  taint  of  alcohol  upon  the  breath  is  lacking,  the  pulse 
is  likely  to  be  of  high  tension  and  the  patient  may  exhale  a  urinous  odor. 
The  pupils  are  variable;  the  urine  when  drawn  by  catheter  shows  the  pres- 
ence of  albumin  and  casts. 

A  consideration  of  acute  alcoholism  is  not  complete  without  mention  of 
the  very  serious  effects  of  indulgence  in  diluted  methyl  alcohol  (wood  alcohol). 
This  liquid  is  often  drunk  by  confurmed  alcoholics  when  it  is  impossible  to 
procure  ordinary  liquors.  The  effects  of  this  form  of  alcohol  are  more  pro- 
longed than  those  of  ethyl  alcohol,  lasting  from  2  to  4  days,  while  those  of  the 


3IO 


THE    INTOXICATIONS. 


latter  seldom  persist  for  more  than  one-quarter  of  this  time.  The  most  per- 
manent effect  is  upon  the  optic  nerves,  blindness,  which  may  last  for  a  long 
time,  and  optic  neuritis  are  common  sequences  of  the  ingestion  of  this  sub- 
stance.   (See  also  p.  316.) 

Treatment.  Recovery  from  the  acute  effects  of  alcohol  is  usual  even  if  no 
treatment  is  administered;  the  event  may,  however,  be  hastened  by  thoroughly 
washing  out  the  stomach,  or,  if  the  patient  is  able  to  swallow,  by  giving  an 
emetic  consisting  of  20  grains  (1.33)  each  of  powdered  ipecac  and  zinc  sulphate, 
or  of  warm  mustard  water — 2  drachms  (8.0)  to  8  ounces  (250.0).  The  hypo- 
dermatic administration  of  tV  to  to  of  a  grain  (0.0044  to  0.006)  of  apomor- 
phine  hydrochloride  is  an  eflScient  method  of  relieving  the  stomach  of  its 
contents  and  at  the  same  time  bringing  about  a  diminution  of  violent  nervous 
symptoms  if  these  are  present.  These  latter  may  be  usually  controlled  by 
the  administration  of  hydrated  chloral  in  dose  of  10  to  20  grains  (0.66  to  1.33) 
with  I  or  2  drachms  (4.0  to  8.0)  of  sodium  bromide.  If  stimulation  is  nec- 
essary the  patient  may  receive  a  drachm  (4.0)  of  aromatic  spirit  of -ammonia 
and  if  there  is  any  tendency  to  collapse,  frictions  and  hot  applications  should 
be  employed.  When  convulsions  are  present,  which  is  rarely  the  case,  a 
little  chloroform  should  be  given  by  inhalation  until  the  sedatives  given  by 
mouth  have  had  time  to  exert  their  effect. 

Chronic  Alcoholism. 

Definition. ,  A  condition  resulting  from  the  habitual  and  intemperate 
use  of  alcoholic  beverages.  What  constitutes  the  "intemperate  use"  of 
alcohol  cannot  be  definitely  stated,  for  certain  individuals  are  able  to  take 
without  apparent  harm  quantities  of  this  substance  which  would  exert,  in 
more  susceptible  subjects,  most  marked  untoward  effects. 

Dipsomania  is  a  form  of  chronic  alcoholism,  the  tendency  to  which  is 
hereditary,  which  is  characterized  by  a  periodic  desire  for  alcoholic  excess 
and  is  evidenced  by  debauches  at  varying  intervals,  the  subject  being  wholly 
free  from  the  craving  during  the  intervening  periods. 

Effects  of  Chronic  Alcoholic  Poisoning.  Among  the  common  results  of 
chronic  alcoholism  are  chronic  gastritis,  gastric  dilatation,  especially  in  beer 
drinkers,  hepatic  cirrhosis,  delirium  tremens  and  mania.  Many  other  diseases 
have  been  attributed  to  the  effects  of  the  chronic  use  of  alcohol  among  which 
may  be  cited  gout,  peripheral  neuritis,  pachymeningitis,  organic  heart  disease 
and  chronic  nephritis;  in  fact,  but  few  organs  and  tissues  are  not  changed  in 
some  way  in  chronic  alcoholism  and  its  results.  Of  the  changes  met 
in  this  condition  two  groups  are  described,  namely  sclerosis  and  steatosis. 
While  these  anatomical  alterations  are  in  process  of  development  the  exterior 
of  the  body  assumes  characteristic  appearances.     The  individual  may  be 


CHRONIC    ALCOHOLISM.  31I 

either  pale  and  flabby,  but  fat,  with  a  heavy  and  imbecile  expression  or  he 
may  have  a  dusky  red  or  purplish,  pimply  and  bloated  skin,  with  swelling 
under  the  eyes,  yellow  and  injected  conjunctivae,  and  blue  and  thickened 
lips. 

Alcoholics  are  especially  likely  to  contract  pneumonia,  tuberculosis  and 
other  infectious  diseases,  and,  when  attacked  by  them,  show  less  resisting 
power  than  do  previously  healthy  persons.  They  are  also  bad  subjects  for 
surgical  operations  and  bear  anaesthesia  poorly. 

The  post  mortem  changes  in  the  organs  and  tissues  of  alcoholic  individuals 
show  no  characteristic  changes,  there  is  often  found,  however,  in  patients 
dead  from  mania  a  potic  an  oedematous  condition  of  the  brain  and  its  mem- 
branes, the  so-called  ivet  brain. 

Symptoms.  These  are  referable  to  the  various  organs  and  systems  whose 
functions  have  been  impaired  and  whose  structiure  has  been  altered  by  the 
effect  of  the  alcohol. 

The  Digestive  System.  Chronic  catarrhal  gastritis  is  an  almost  constant 
affection  in  the  chronic  alcoholic.  It  is  evidenced  by  anorexia,  foul  tongue 
and  breath,  constipation,  nausea  and  vomiting,  especially  before  eating  in 
the  morning,  the  so  called  "  water  brash."  Often  these  symptoms  are  relieved 
by  the  day's  first  potation. 

The  liver  is  subject  to  definite  changes  partly  as  a  result  of  chronic  over- 
indulgence in  alcohol  and  from  accessory  products  used  in  manufacture 
or  from  additional  substances  introduced  in  "blending."  From  these 
arise  symptoms  in  accordance  with  the  existing  conditions  of  cirrhosis,  fatty 
degeneration,  etc.  These  changes  by  no  means  always  occur  but  are  fre- 
quent and  as  a  result  of  the  compression  of  the  portal  circulation,  due  to  the 
cirrhosis  and  consequent  contraction  of  the  new  interstitial  tissue,  various 
manifestations  appear,  such  as  those  due  to  congestion  of  the  gastric  mucous 
membrane,  haemorrhages  from  the  alimentary  tract,  haemorrhoids,  splenic 
enlargement,  etc.  The  characteristic  facies  of  the  alcoholic  with  its  dilated 
veins,  reddened  nose — which  is  often  the  acne  rosacea  of  the  dermatologists — 
the  swellings  beneath  the  eyes  and  the  icteric  conjunctivae,  usually  accom- 
panies the  disorders  of  the  digestive  tract  and  liver. 

From  the  changes  in  the  circulatory  system  the  symptoms  due  to  cardiac, 
renal  and  arterial  disease  result.  Of  these  vertigo,  apoplectic  seizures  and 
the  various  other  manifestations  of  arterial  degeneration  are  most  important. 

The  Nervous  System.  Such  symptoms  as  tremors  of  the  hands  and  tongue 
and  unsteadiness  in  the  control  of  muscular  acts  are  very  common;  the  mental- 
ity is  sluggish,  the  patient  is  irritable,  restless  and  deteriorates  morally;  the 
memory  is  impaired  and  the  intellect  becomes  weakened  generally;  finally 
dementia  and  insanity  may  supervene.  Multiple  peripheral  neuritis  is  fre- 
quent and  will  be  considered  elsewhere.     Epilepsy  may  also  occur  as  a  sequence 


312 


THE    INTOXICATIONS. 


of  chronic  alcoholism  but  is  likely  to  disappear  with  the  resumption  of  proper 
habits.  At  times  there  develops  with  an  alcoholic  neuritis,  and  sometimes  by 
itself,  a  peculiar  condition  characterized  by  hallucinations  of  sight,  labial 
tremors,  thickness  of  speech,  impairment  of  memory,  disordered  ideas  of 
time  and  space  and  imaginative  explanations  of  actual  incidents,  to  which 
the  term  psychosis  polyneuritica  or  Korsakoff's  disease  has  been  applied. 

Changes  in  the  nervous  system  are  found  after  death  but  are  not  charac- 
teristic; of  these  hsemorrhagic  pachymeningitis,  thickenings  and  opacities 
of  the  pial  and  arachnoid  membranes,  and  even,  in  advanced  instances,  en- 
cephalomeningitis  with  meningeal  adhesions  should  be  mentioned. 

Treatment.  Chronic  alcohoUsm  can  hardly  be  treated  satisfactorily  at 
the  patient's  home;  success  is  far  more  readily  attained  at  an  institution  where 
outside  influences  can  be  excluded,  alcohol  cannot  be  obtained  unless  con- 
sidered advisable  by  the  physician  in  charge  and  the  patient  can  be  kept 
under  the  strict  supervision  of  attendants.  An  excellent  substitute  for  insti- 
tutional treatment  is  a  prolonged  sea  voyage  or  a  sojourn  in  the  woods  such 
as  is  afforded  by  a  hunting  or  fishing  trip  where  no  alcohol  is  taken  and  the 
inebriate  is  associated  with  one  or  more  congenial  companions  who  are  not 
drinkers.  It  is  the  present  uniformly  held  belief  that  an  entire  withdrawal 
of  the  alcohol  is  better  than  a  gradual  "tapering  off"  unless  the  abstention 
results  in  an  attack  of  delirium  tremens,  when  it  is  usually  necessary  to  allow 
the  drug  in  varying  amount.  The  substitution  of  narcotics,  such  as  chloral, 
cocaine  and  the  like,  for  alcohol  is  to  be  unhesitatingly  condemned.  Sleepless- 
ness and  nervousness  may  be  controlled  by  the  administration  of  the  milder 
hypnotics  such  as  the  bromides,  sulphonmethane  (sulphonal),  sulphon- 
ethylmethane  (trional),  veronal  and  paraldehyde.  Morphine  should  not  be 
used  unless  the  patient's  condition  renders  it  absolutely  necessary  and  other 
sedatives  have  failed.  Even  then  it  should  not  be  prescribed  as  a  routine 
but  occasionally  only,  for  the  danger  of  acquiring  the  habit  is  great. 

Hyoscine  hydrobromide  has  recently  been  advocated  as  an  excellent  means 
of  allaying  the  desire  for  alcohol  and  the  nervous  symptoms  which  follow  its 
suspension.  It  may,  if  necessary,  be  given  to  the  physiological  limit  even 
to  the  production  of  dryness  of  the  mouth  and  delirium.  Doses  of  tttti 
of  a  grain  (0.0006)  may  be  administered  hypodermatically  every  2  or  3  hours 
until  the  nervous  manifestations  are  relieved.  These  may  be  kept  in  a  state 
of  abatement  by  less  frequent  doses  until  the  drug  finally  is  entirely  stopped. 

The  much  exploited  gold  cure  and  other  advertised  institutional  treat- 
ments possess  no  special  recommendation. 

The  addition  of  apomorphine  or  other  substances  to  the  liquor  taken  by 
the  patient  and  the  hypodermatic  administration  of  the  former  drug  after 
drinking  may  produce  a  distaste  for  alcohol.  It  has  also  been  asserted  that 
hypodermatic  doses  of  t^tj  of  a  grain  (0.0006)  of  atropine  sulphate  given 


DELIRIUM   TREMENS.  313 

several  times  a  day  will  shortly  render  alcohol  distasteful  to  the  patient  and 
productive  of  emesis  without  the  addition  of  nauseating  drugs. 

During  treatment  the  patient's  digestion  should  be  kept  in  as  good 
condition  as  possible,  the  bowels  should  be  regulated  by  means  of  mild  laxa- 
tives or  by  occasional  purgation  with  fractional  doses  of  calomel  followed  by 
a  saline,  and  stomachic  bitters  together  with  such  tonics  as  strychnine  and 
cinchona  are  useful.  Any  tendency  to  circulatory  failure  must  be  combated 
by  the  ordinary  means,  strychnine,  digitalis,  etc.  Acute  syncope  or  collapse 
necessitates  the  hypodermatic  administration  of  diffusible  cardiac  stimu- 
lants; such  as  camphor  and  aether,  and  of  the  aromatic  spirit  of  ammonia  or 
the  compound  spirit  of  aether  by  mouth. 

The  diet  should  be  nourishing,  abundant  and  easily  digestible.  Tea  and 
coffee,  on  account  of  their  stimulant  properties  may  be  allowed. 


Delirium  Tremens. 

Synonym.    Mania  a  Potu. 

Definition.  An  effect  of  the  prolonged  use  of  alcohol  characterized  by 
delirium  with  hallucinations  and  extreme  prostration. 

Symptoms.  The  syndrome  delirium  tremens  is  a  result  of  the  prolonged 
action  of  alcohol  upon  the  cerebral  cells  but  is  often  induced  by  a  sudden 
withdrawal  of  the  drug.  Alcoholic  excess  in  a  temperate  individual  does 
not  bring  on  an  attack  but  a  debauch  may  be  followed,  in  the  case  of  a  chronic 
alcoholic,  by  typical  mania  a  potu.  Alcoholic  subjects  are  very  prone  to 
attacks  when  prostrated  by  acute  disease,  particularly  pneumonia.  Delirium 
tremens  is  also  a  frequent  consequence  in  alcoholics  of  a  mental  shock  or  physical 
injury  such  as  a  fractured  limb  or  other  result  of  traumatism.  Prevention 
may  be  possible,  in  the  latter  instances,  by  allowing  these  patients  alcohol 
in  moderate  quantity. 

The  onset  of  an  attack  is  marked  by  sleeplessness,  restlessness  and  depres- 
sion; these  symptoms  are  shortly  succeeded  by  a  delirium  characterized  by 
hallucinations  of  sight  and  hearing.  Talking  is  continuous  and  incoherent 
and  restraint  may  be  necessary,  for  the  patient  may  desire  to  leave  the  house 
on  imaginary  business.  The  delusions  of  sight  may  take  the  form  of  animals 
rats,  mice,  snakes,  insects,  etc.,  which  the  patient  imagines  are  pursuing  him  or 
crawling  about  his  bed  or  over  his  body.  The  fear  induced  is  intense  and 
constant  watching  is  necessary  to  prevent  attempts  to  escape.  The  hallu- 
cinations of  hearing  are  less  usual  but  conversations  with  imaginary  persons 
may  be  carried  on,  imaginary  voices  and  noises  may  be  heard.  Muscular 
tremor  is  marked  and  sleep  is  impossible.  There  is  extreme  weakness  and 
the  pulse  is  soft,  frequent,  compressible  and,  perhaps,  irregular.     The  tern- 


314  THE    INTOXICATIONS. 

perature  is  elevated  to  101°  to  103°  F.  (38.3°  to  39.5°  C.)  unless  acute  com- 
plications are  present,  when  it  is  higher. 

The  diagnosis  is  simple.  The  patient  should  be  thoroughly  examined 
when  first  seen  for  surgical  injuries  and  daily  physical  examination  of  the 
lungs  is  necessary,  for  congestion  at  the  bases  is  frequent  and  may  develop 
into  pneumonia;  on  the  other  hand  pneumonia,  especially  that  at  the  pulmonary 
apices  may  be  accompanied  by  a  delirium  resembling  that  of  mania  a  potu. 
Meningitis,  a  serous  form  of  which  (wei  brain)  is  often  present,  simulates 
in  its  symptoms  delirium  tremens,  but  may  be  differentiated  from  the 
latter  condition  by  an  absence  of  alcoholic  history  and  the  patient's 
appearance. 

The  prognosis  varies,  but,  if  there  are  no  complications  present,  recovery 
usually  takes  place  within  a  week,  the  hallucinations,  sleeplessness  and  tremors 
gradually  disappearing.  In  hospitals,  however,  the  tj-pe  of  alcoholic  subject 
generally  observed  is  in  a  weakened  and  debilitated  state  and  the  death  rate 
is  consequently  high,  the  patient  gradually  faUing  into  the  typhoid  condition 
with  feeble  and  dicrotic  pulse,  dry  and  cracked  tongue,  and  low,  muttering 
delirium;  death  from  cardiac  failure  supervenes  in  a  great  number  of  instances. 
In  patients  who  recover  recurrences  are  common. 

Treatment.  The  patient  should  be  put  to  bed  in  a  quiet  darkened  room; 
alcohol  should  be  withdrawn  unless  its  administration  is  necessary  to  combat 
adynamia;  even  if  there  is  marked  cardiac  weakness  in  many  instances  it  is 
preferable  to  stimulate  by  means  of  ammonium  which  is  best  administered 
as  the  solution  of  the  acetate  (liquor  ammonii  acetatis)  in  doses  of  5  an  ounce 
(15.0)  repeated  every  2  or  3  hours  if  necessary.  The  aromatic  spirit  is  also 
useful  and  may  be  given  in  doses  of  J  to  i  drachm  (2.0  to  4.0).  Strychnine 
sulphate,  -jV  of  a  grain  (0.002)  or  more,  if  indications  are  present,  may  be 
employed  as  well. 

The  relief  of  the  sleeplessness  is  most  important  and  may  be  accomplished 
by  the  administration  of  the  bromides  and  chloral,  ^  drachm  (2.0)  of  sodium 
bromide  with  10  to  15  grains  (0.66  to  i.o)  of  hydrated  chloral  often  being 
sufficient.  Chloral,  however,  should  not  be  employed  if  there  is  tendency 
to  heart  weakness.  The  writer  has  obtained  excellent  results  in  his  service 
in  the  alcoholic  wards  of  Bellevue  Hospital  with  paraldehyde  in  doses  of 
2  drachms  (8.0)  frequently  repeated  if  necessary.  Sulphonethylmethane 
(trional),  in  doses  of  10  to  20  grains  (0.66  to  1.33),  is  also  useful  and 
often  9,cts  well  when  given  in  combination  with  5  grains  (0.33)  of  veronal. 
If  the  delirium  is  uncontrollable  by  other  means  hyoscine  hydrobromide — 
T^TT  of  a  grain  (0.0006) — may  be  given  hypodermatically.  Morphine  should 
be  administered  with  caution  if  at  all;  when  all  other  measures  fail  it  may  be 
given  hypodermatically  in  doses  of  J  of  a  grain  (0.016)  but  should  seldom 
be  repeated  more  than  twice,  the  effects  being  watched  with  great  care.     Cold 


METHYL    ALCOHOL    POISONING.  315 

baths  and  hot  or  cold  packs,  repeated  if  necessary,  are  often  useful  in  the 
relief  of  the  restlessness. 

If  there  are  symptoms  indicating  meningeal  involvement  (wet  brain), 
such  as  stiffness  and  rigidity  of  the  neck,  etc.,  the  ice  helmet  should  be  applied. 

Restraint  is  often  necessary  to  keep  the  patient  in  bed  and  here  the  employ- 
ment of  a  folded  sheet  placed  across  the  body  and  pinned  under  the  mattress 
is  to  be  preferred  to  straps. 

At  the  beginning  of  the  treatment  the  bowels  should  be  freely  moved  and 
throughout  the  course  of  the  affection  the  channels  of  elimination  should  be 
kept  open  by  means  of  frequent  draughts  of  water  and  laxatives  when  neces- 
sary. 

The  patient's  strength  should  be  maintained  by  means  of  frequent  feeding 
with  easily  digestible  and  assimilable  foods,  such  as  milk,  peptonized  if  pre- 
ferred, and  nourishing  soups.  As  the  symptoms  ameliorate  a  gradual  return 
to  ordinary  diet  should  be  allowed. 

METHYL  ALCOHOL  POISONING. 

Of  late  years  numerous  instances  of  poisoning  by  methyl  (wood)  alcohol 
or  Columbian  spirits  have  been  reported;  this  is  probably  due  in  great  measure 
to  the  fact  that  methyl  alcohol  is  being  used  as  a  substitute  for  ethyl  (grain) 
alcohol  in  the  manufacture  of  many  preparations.  Even  such  substances  as 
flavoring  essences,  etc.,  have  been  made  with  the  cheaper  alcohol,  while  it 
is  common  enough  to  find  varnishes,  bay  rum,  cologne,  so-called  witch  hazel 
extracts  and  the  like  mixed  with  wood  alcohol;  it  is  probable,  however,  that 
the  recently  enacted  pure  food  and  drug  laws  will,  to  a  great  extent,  do  away 
with  this  pernicious  form  of  adulteration. 

Even  the  inhalation  of  the  fumes  of  methyl  alcohol,  as  may  occur  after  the 
interiors  of  beer  vats  or  small  rooms  have  been  varnished,  may  cause  toxic 
symptoms,  and  it  is  quite  probable  that  in  susceptible  individuals  even  a 
single  "alcohol  rub"  may  produce  untoward  manifestations  through  the 
absorption  of  the  alcohol  through  the  skin.  The  larger  number  of  instances, 
however,  of  methyl  alcohol  intoxication  are  the  result  of  drinking  the  fluid, 
either  diluted  with  water  or  unknowingly  in  the  form  of  adulterated  liquors, 
ginger  essence,  cologne,  etc.  Idiosyncrasy  apparently  plays  an  important 
part  in  the  type  and  severity  of  the  toxic  symptoms  for,  as  stated  by  Buller 
and  Wood,  some  individuals  are  largel}'  immune  so  far  as  permanent  damage 
to  the  organism  is  concerned.  Of  ten  persons  who  take  10  ounces  (300.0)  of 
Columbian  spirit  within  three  hours  all  will  exhibit  marked  abdominal  distress 
and  four  will  die,  two  of  these  becoming  bhnd  before  death  takes  place.  Six 
will  finally  recover  and  of  these  two  will  remain  permanently  blind.     If  larger 


3l6  THE    INTOXICATIONS. 

amounts  than  the  above  are  taken  the  proportion  of  mortality  and  blindness 
will  be  greater. 

Methyl  alcohol  intoxication  occurs  in  an  acute  and  a  chronic  type.  In 
the  acute  type  the  symptoms  are,  in  general,  analogous  to  those  observed  in 
individuals  poisoned  by  grain  alcohol  (see  the  section  upon  acute  alcoholism) 
but  the  manifestations  are  produced  more  slowly  than  is  the  case  with  the 
latter  substance  and  the  duration  of  the  intoxication  is  more  persistent. 

The  first  noticeable  symptom  of  acute  methyl  alcohol  poisoning  may  be  a 
state  of  exhilaration  and  excitement  resembling  that  of  ordinary  drunkenness; 
in  almost  all  instances  the  patients  have  complained  of  marked  headache, 
nausea,  active  and  persistent  emesis  and  profuse  perspiration.  Pupillary 
dilatation  is  the  rule,  delirium  is  frequent  and  is  usually  followed  by  coma 
which  may  continue  for  several  days  and  sometimes  ends  in  death. 

The  most  interesting  and  characteristic  symptom  of  methyl  alcohol  intoxic- 
ation is  blindness;  this  has  been  observed  in  a  large  proportion  of  individuals 
who  have  suffered  from  the  effects  of  excessive  amounts  of  this  substance 
and  may  be  transient  or  permanent.  Impairment  of  vision  is  very  commonly 
seen  and  while  in  such  instances  the  normal  sight  may  be  recovered,  in  those 
instances  in  which  the  blindness  has  been  total  it  is  a  rare  occurrence  for 
the  eyes  to  regain  their  normal  power.  The  ocular  disturbance  may  be  the 
only  symptom  of  the  intoxication  which  is  evidenced  by  the  patient,  here  the 
blindness  may  not  appear  for  several  days  after  the  ingestion  of  the  alcohol. 
Following  the  incidence  of  the  blindness  the  sight  may  temporarily  return 
only  to  be  lost  again  after  a  few  days  or  weeks. 

The  amaurosis  is  the  result  of  optic  nerve  atrophy;  at  times  the  color  sense 
is  chiefly  affected  and  in  other  instances,  while  peripheral  vision  is  preserved, 
the  visual  fields  are  contracted.     Absolute  central  scotoma  is  very  constant. 

The  fatal  dose  of  methyl  alcohol  is  variable;  death  has  followed  the  inges- 
tion of  one-half  pint  (|  litre)  and  in  other  instances  considerably  less  than  this 
quantity  has  brought  about  a  fatal  outcome. 

The  prognosis  is  distinctly  bad.  Death  has  followed  large  doses  in  a  few- 
hours,  but  in  general  it  does  not  occur  for  a  day  or  two. 

Prevention.  This  may  be  to  some  extent  accomplished  by  prohibiting  the 
sale  of  deodorized  methyl  alcohol  in  all  its  forms.  All  preparations,  con- 
taining the  substance  should  be  labeled  poison  and  individuals  using  it  as 
an  adulterant  for  food  or  drink  should  be  prosecuted.  When  used  in  the 
arts  is  may  be  made  undrinkable  by  the  addition  of  a  small  percentage  of 
naphthalin. 

Treatment.  The  first  indication  is  immediate  emptying  of  the  stomach 
by  means  of  gastric  lavage  and  the  intestines  by  means  of  purgation  and 
high  rectal  irrigations.  The  cardiac  and  respiratory  weakness  should  be 
combated  by  such  stimulants  as  ethyl  alcohol,  strychnine,  digitalis  and  caffeine. 


CHLORALISM.  317 

The  collapse  necessitates  the  employment  of  hot  applications  to  the  body 
and  extremities  in  connection  with  rectal  injections  of  hot  coffee.  It  has 
been  shown  that  the  administration  to  animals  of  sodium  bisulphite  with 
methyl  alcohol  increases  the  formic  acid  output  in  the  urine;  as  methyl 
alcohol  is  excreted,  in  part,  at  least,  in  the  form  of  this  latter  substance,  sodium 
bisulphite  might  prove  useful  as  a  therapeutic  agent. 

Little  is  to  be  expected  of  treatment  directed  at  the  amaurosis.  The  use 
of  pilocarpine,  potassium  iodide  in  the  early  stages,  and  the  later  administra- 
tion of  strychnine,  is  advised. 

The  chronic  type  of  methyl  alcohol  intoxication  may  follow  the  frequent 
taking  of  small  quantities  of  liquids  (essence  of  ginger,  peppermint,  cologne, 
etc.)  and  is  an  insidious  and  doubtless  not  a  rare  form  of  poisoning.  It  is 
difficult  of  recognition  in  the  absence  of  suggestive  history,  but  it  is  quite 
certain  that  it  results  in  disorders  referable  to  the  eyes  and  the  digestive  and 
nervous  systems. 

CHLORALISM. 

The  chloral  habit  is  very  easily  acquired  by  individuals  who  have  employed 
hydrated  chloral  in  ordinary  doses  for  even  a  short  time  for  the  relief  of  sleep- 
lessness or  any  other  purpose,  and,  once  estabhshed,  produces  serious  results 
and  is  difficult  of  cure. 

Symptoms.  The  patient  suffers  from  digestive  disturbances  and  diar- 
rhoea, extreme  mental  and  physical  weakness  with  sudden  flushings  due  to 
vaso-motor  derangements,  cardiac  palpitation,  and  from  erythematous  erup- 
tions, usually  purplish  in  color,  and  especially  affecting  the  face;  sometimes 
they  are  found  upon  the  mucous  membranes.  In  some  instances  bed  sores 
and  ulcerations  appear.  Dyspnoea,  due  to  depression  of  the  heart  action  and 
the  respiration  and  the  general  bodily  weakness,  is  a  marked  symptom;  the 
temperature  is  often  subnormal.  The  patient  sleeps  only  when  under  the 
influence  of  the  accustomed  hj^notic  and  death  in  collapse  may  at  any  time 
follow  an  over-dose,  since  by  reason  of  the  cumulative  effects  of  the  poison 
in  the  system  the  vital  functions  are  greatly  impaired  and  elimination  is  ren- 
dered impossible.  Sudden  withdrawal  of  the  drug  may  cause  symptoms 
analogous  to  those  of  delirium  tremens;  such  a  condition  is  dangerous,  as 
fatty  degeneration  of  the  heart  is  likely  to  be  present. 

Treatment  should  be  carried  out  upon  the  same  lines  as  those  to  be  described 
in  dealing  with  the  morphine  habit.  Isolation  and  careful  attendance  are 
necessary;  stimulation  of  the  heart  by  means  of  ammonia,  strychnine  and 
digitalis  is  indicated;  the  sleeplessness  may  be  controlled  by  the  bromides, 
sulphonmethane    (sulphonal),    sulphonethylmethane    (trional)    or    veronal 


3l8  THE    INTOXICATIONS. 

a  combination  of  the  two  last  consisting  of  lo  or  15  grains  (0.66  to  i.o)  of 
trional  to  5  grains  (0.33)  of  veronal  is  often  quite  effectual.  Morphine  may 
be  employed  only  as  a  last  resort.  Tonics,  plenty  of  nourishing  food  and 
congenial  occupations,  together  with  electricity  and  massage,  are  useful  ad- 
juncts to  treatment. 

SULPHONMETHANE  (SULPHONAL)  POISONING. 

Fatal  instances  of  poisoning  by  sulphonal  have  been  reported  as  occurring 
from  small  doses  of  this  drug  continued  for  long  periods.  The  excretion  of 
this  substance  seems  to  be  slower  than  its  absorption  and  consequently  there 
is  a  tendency  to  a  cumulative  action.  This  may  lead  to  gastritis,  renal  disease 
and  certain  not  very  clearly  understood  changes  in  the  blood.  As  a  result 
of  the  last  there  is  a  characteristic  discoloration  of  the  lurine  due  to  the  presence 
in  it  of  a  reddish-brown  pigment,  hsematoporphyrin,  which  is  an  iron- 
free  product  of  the  decomposition  of  haemoglobin.  This  occurs  chiefly 
in  women  and  is  associated  with  constipation,  vomiting  and  gastric  pain, 
weakness  and  ataxia,  confusion  and  partial  paralysis;  eventually  suppression 
of  the  urine,  collapse  and  death  may  result.  Though  the  continued  use  of  the 
drug  may  not  induce  these  grave  manifestations  it  may  be  attended  by  severe 
functional  disturbances  such  as  mental,  moral  and  physical  deterioration, 
indigestion,  impaired  nutrition  and  cutaneous  eruptions. 

Enormous  single  doses  have  been  known  to  cause  paralysis  of  the  sphincters, 
anuria,  subnormal  temperature  and,  as  a  late  symptom,  respiratory  depression. 

Treatment.  The  untoward  effects  of  sulphonal  can  usually  be  avoided  by 
intermitting  its  administration  from  time  to  time  and  by  the  daily  use  of  the 
alkaline  mineral  waters  either  still  or  carbonated.  When  toxic  symptoms 
have  appeared  the  drug  should  be  stopped  at  once.  The  treatment  otherwise 
is  symptomatic  and  supportive. 

SULPHONETHYLMETHANE  (TRIONAL)  POISONING. 

The  symptoms  resulting  from  the  continued  use  of  trional  are  analogous 
to  those  of  sulphonal  poisoning.  They  consist  of  hebetude,  drowsiness, 
anorexia,  and  muscular  weakness;  the  frequency  of  the  pulse  is  diminished 
and,  in  marked  instances,  vertigo,  ataxia  and,  more  rarely,  hallucinations 
and  delirium  may  be  observed.  Haematoporphyrinuria  occurs  and  upon 
its  appearance  the  administration  of  the  drug  should  be  stopped. 

Treatment  consists,  as  in  sulphonal  intoxication,  of  the  employment  of 
means  to  favor  elimination  and  to  support  the  patient.  The  symptoms, 
should  be  combated  by  the  indicated  measures  as  they  arise. 


VERONAL    POISONING,  319 

VERONAL  POISONING. 

A  few  instances  of  poisoning  due  to  this  drug  have  been  reported.  In 
one  patient  its  administration  resulted  in  a  febrile  movement  which  lasted 
about  a  week,  dryness  of  the  mouth,  a  morbilliform  rash  upon  the  face,  chest 
and  arms,  which  later  became  confluent  and  was  followed  by  a  vesicular  and 
bullous  eruption  upon  the  mucous  membrane  of  the  mouth  and  pharynx, 
conjunctivitis  and  aural  pain.  A  dose  of  24  grains  (1.66)  has  produced  the 
symptoms  of  narcotic  poisoning  followed  by  a  universal  cutaneous  erythema 
which  recurred  after  a  second  dose  and  in  addition  the  patient  suffered  from 
periodic  delirium. 

The  prolonged  employment  of  veronal  may  result  in  the  appearance  of 
cerebral  dulness,  drowsiness,  a  staggering  gait,  nausea  and  vomiting  and 
haematoporphyrinuria. 

Treatment  consists  in  stopping  the  drug,  alternation  with  h\^notics  of  other 
types,  the  administration  of  alkaline  mineral  water  and  securing  a  daily 
movement  of  the  bowels. 

MORPHINISM. 

Synonyms.     Morphinomania;  The  Morphine  Habit. 

The  morphine  habit  is  often  acquired  by  patients  for  whom  the  drug  has 
been  prescribed  by  a  physician  to  control  obstinate  pain  or  sleeplessness, 
or  more  frequently  from  self-administration  or  the  use  of  certain  patent 
medicines.  It  is  particularly  frequent  among  women  who  are  affected  with 
painful  conditions  and  among  physicians  themselves.  Individuals  of  neurotic 
tendency  are  more  subject  to  the  contraction  of  the  habit  than  those  whose 
nervous  systems  are  stable,  and  heredity  is  a  recognized  predisposing  aetio- 
logical  factor.  Alcoholics  often  become  morphine  habitues,  the  drug  being 
first  taken  as  an  aid  in  the  attempt  to  overcome  the  craving  for  liquor.  The 
morphine  is  taken  either  by  mouth  or  hypodermatically,  and,  while  certain 
subjects  continue  to  take  the  same  small  quantity  of  the  drug,  the  tendency 
is  to  gradually  increase  the  amount  until  30  grains  (2.0)  a  day  or  even  more 
are  employed.  In  the  East  opium  eating  and  smoking  are  as  common 
as  the  use  of  tobacco  is  with  us  but  the  oriental  constitution  seems  much 
better  able  to  withstand  the  effects  of  the  drug  than  does  that  of  the 
Caucasian. 

Symptoms.  The  continued  use  of  small  doses  of  morphine  may  for  a 
long  time  result  in  no  marked  manifestations  other  than  a  craving  for  the 
drug,  but  sooner  or  later  the  functions  of  both  body  and  mind  become  affected. 
While  under  the  influence  of  the  morphine  the  patient  may  feel  well,  but  as 
the  effects  disappear  mental  disquietude,  depression,  nausea  and  perhaps 


320  THE   INTOXICATIONS. 

colicky  abdominal  pain  follow,  which  can  be  relieved  only  by  further  recourse 
to  the  drug.  The  character  of  the  morphinomaniac  becomes  deteriorated 
and  is  typified  by  lack  of  self-control  and  of  moral  sense — the  subjects  of  the 
habit  being  notoriously  untruthful — there  is  an  irritability  of  temperament, 
sleeplessness  is  frequent,  the  appetite  is  poor  and  nutrition  becomes  impaired; 
the  pulse  is  weak  and  rapid,  sweating  and  itching  of  the  skin  are  common 
and  constipation  is  the  rule.  The  appearance  of  the  patient  is  somewhat 
typical,  the  skin  being  sallow,  the  pupils  dilated  and  the  facies  prematurely 
aged;  oedema  of  the  limbs  may  be  present.  When  under  the  influence  of  the 
drug  the  pupils  are  contracted  and  the  mental  and  physical  condition  usually 
seems  much  more  normal.  Morphine  habitues  finally  become  subject  to 
muscular  tremors,  and,  women  particularly,  are  likely  to  exhibit  hysteric 
and  neurasthenic  symptoms.  The  deteriorated  constitution  becomes  an  easy 
prey  to  disease  and  usually  the  end  comes  as  a  result  of  intercurrent  affection 
or  of  weakness  induced  by  the  lack  of  the  maintenance  of  nutrition. 

Certain  subjects  live  to  moderate  old  age  and  even,  though  the  habit  is 
continued,  are  able  to  transact  the  usual  duties  of  life;  these,  however,  are 
generally  the  rare  individuals  who  get  along  upon  a  small  and  not  increased 
quantity  of  the  drug. 

The  prognosis  is  variable,  depending  upon  the  strength  of  character  of  the 
patient  and  upon  his  surroundings.     Relapse  is  very  common. 

Treatment.  Much  may  be  done  by  the  physician  in  the  way  of  prevention 
of  the  morphine  habit.  The  indiscriminate  prescribing  of  the  drug  cannot 
be  too  strongly  condemned  and  it  is  a  positive  crime  to  put  a  hypodermatic 
syringe  into  the  hands  of  a  patient  to  be  used  in  the  control  of  pain  or  sleep- 
lessness. When  morphine  is  indicated  it  is  an  invaluable  drug,  but  it  is  best 
not  to  tell  the  patient  that  he  is  receiving  it,  and  all  prescriptions  should  be 
marked  "not  to  be  refilled  without  order  of  the  physician." 

In  the  treatment  of  morphinism  institutional  seclusion  is  an  absolute  essen- 
tial, for  the  closest  watchfulness  upon  the  part  of  attendants  cannot  prevent  the 
patient  from  procuring  the  drug  if  he  is  in  his  own  home;  even  in  institutions 
it  is  often  difficult  to  prevent  his  access  to  morphine  for  friends  may  be  per- 
suaded and  servants  bribed  to  obtain  it  for  him.  The  treatment  is  one  offering 
immense  difficulties  at  best,  on  account  of  the  degraded  moral  condition  of  the 
habitue  and  is  very  frequently  unsuccessful  in  effecting  a  cure.  Isolation  is 
necessary  and  the  patient  should  be  watched  with  the  utmost  vigilance  to 
prevent  him  from  securing  the  drug  surreptitiously.  The  morphine  must 
not  be  withdrawn  suddenly,  since  this  is  likely  to  be  attended  by  collapse 
and  aggravated  mental  disturbance,  but  the  quantity  should  be  gradually 
diminished  until  it  is  considered  wise  to  stop  it  altogether,  which  can  usually 
be  done  at  the  end  of  about  a  week.  The  withdrawal  of  the  morphine  is 
followed  in  many  instances  by  diarrhoea,  insomnia,  irritability  and  extreme 


MORPHINISM.  321 

mental  and  bodily  depression.  Medication  is  often  necessary  to  combat 
these  symptoms.  Stimulation  of  the  heart  for  weakness,  if  this  is  present,  by 
means  of  ammonium,  strychnine,  digitalis  or  caffeine  may  be  indicated;  alcohol 
should  not  be  employed  on  account  of  the  possibiHty  of  inducing  its  habitual 
use;  cocaine  is  contraindicated  for  the  same  reason.  The  gastric  symptoms 
should  be  relieved  by  appropriate  methods,  and  the  same  is  true  of  constipa- 
tion and  diarrhoea.  The  intestinal  atony  which  is  the  cause  of  the  former 
is  best  combated  by  the  administration  of  physostigmine  salicylate  in  doses 
of  T^-Q  of  a  grain  (0.0006)  twice  a  day;  the  diarrhoea  may  be  controlled  by 
bismuth  subsalicylate  in  20  grain  (1.33)  doses  every  4  hours  or  by  other  salts 
of  this  metal  with  vegetable  astringents.  The  appetite  may  be  stimulated  by 
means  of  the  vegetable  bitters,  and  by  palatable  and  highly  seasoned  food, 
plenty  of  nourishment  being  an  important  consideration;  plenty  of  milk  and 
rich  broths  should  be  given.  The  insomnia  and  nervous  irritability  may  be 
relieved  by  the  bromides,  sulphonmethane  (sulphonal)  in  doses  of  20  grains 
(1.33)  in  warm  milk,  sulphonethylmethane  (trional)  or  veronal  in  doses  of  10 
to  15  grains  (0.66  to  i.o),  and  by  chloral  formamide  (chloralamide)  in  doses 
of  15  grains  (i.o).  Hydrated  chloral  may  be  employed  in  emergency  but 
the  possibility  of  habit  formation  must  not  be  forgotten;  this  drug  is  contra- 
indicated  in  the  presence  of  cardiac  weakness.  Hyoscine  hydrobromide  and 
morphine  itself  are  sometimes  necessary.  The  mental  excitement  may  often 
be  controlled  by  warm  or  cool  baths  or  packs. 

Within  the  past  few  years  treatment  by  means  of  the  systematic  admin- 
istration of  hyoscine  hydrobromide  has  been  advocated.  The  patient  is 
placed  under  the  careful  supervision  of  attendants,  the  morphine  is  stopped 
and  hyoscine  is  given  hypodermatically  in  large  quantity,  even  as  much  as 
j^  of  a  grain  (0.0006)  every  2  or  3  hours,  until  the  restlessness  and  nervous 
irritability  are  under  control.  Sleep  may  not  ensue  but  a  condition  of  semi- 
stupor  may  be  produced  during  which  the  patient  often  talks  incoherently. 
The  physiological  effect  of  the  drug  as  evidenced  by  dryness  of  the  mouth 
may  not  be  noticeable.  The  patient  is  kept  under  the  influence  of  the  hyoscine 
for  several  days  until  the  more  acute  craving  for  morphine  has  disappeared, 
the  effects  of  the  drug  are  then  allowed  to  wear  off  and  in  fortunate  instances 
the  patient  may  have  been  weaned  from  his  habit.  If  there  are  signs  of 
cardiac  failure  stimulation  by  means  of  strychnine  is  indicated.  Rather 
remarkable  cures  have  been  reported  as  resulting  from  this  treatment,  but 
relapse  is  as  common  as  after  other  forms. 

In  conclusion  it  may  be  asserted  that  no  known  drug  appears  to  possess 
any  specific  effect  in  controlling  morphinomania;  no  reliance  can  be  placed 
upon  any  of  the  advertised  cures;  most  of  these  contain  morphine  and  are 
consequently  ineffectual,  the  others  are  made  up  of  inert  drugs  and  are 
frauds. 
21 


322  THE    INTOXICATIONS. 

HASCHISCH  (CANNABIS  INDICA)  POISONING. 

Haschisch  is  largely  employed  in  the  Orient  as  a  stimulant  of  the  psychic 
functions  and  its  moderate  use  does  not  seem  to  be  attended  by  injurious 
effects.  When  taken  to  excess  it  leads  to  tremor,  loss  of  appetite,  muscular 
weakness  and  sometimes  to  mania  and  dementia.  In  some  severe  instances 
convulsive  attacks  have  been  observed  and  among  the  natives  of  India  cata- 
lepsy is  said  to  occur  at  times.  The  drug,  if  employed  by  Caucasians,  would 
probably  cause  more  serious  results  than  are  usual  among  Orientals. 

Death  from  acute  poisoning  is  rare,  and  recovery  has  taken  place  after 
very  large  doses.  Shortly  after  the  administration  of  the  drug  the  patient 
experiences  most  pleasurable  emotions,  everything  seems  to  amuse  him, 
he  becomes  hilarious  and  indulges  in  actions  which  he  realizes  to  be  ridiculous; 
double  consciousness  is  well  marked.  The  patient  is  on  the  best  of  terms 
with  those  about  him  and  passes  into  a  dreamy,  semi-conscious  state  in  which 
he  experiences  ideas  upon  the  most  magnificent  scale;  time  and  space  appear 
to  be  indefinitely  extended.  He  may  say  brilliant  or  witty  things  but  there  is 
little  relevance  in  his  thought  which  changes  rapidly  from  one  subject  to  another. 
He  experiences  delightful  visions;  true  hallucinations  may  be  present.  The 
general  sensibility  is  much  diminished  and  even  complete  anaesthesia  may 
be  noted.  The  pupil  is  usually  somewhat  dilated;  later  the  dreams  alternate 
with  conscious  periods  and  ultimately  the  patient  falls  into  a  quiet  slumber 
from  which  he  awakes  without  any  sensation  of  depression,  but  refreshed 
and  hungry. 

The  effects  of  cannabis  indica  vary  greatly  in  different  individuals  as  a 
result  of  personal  peculiarities  or  of  variations  in  the  strength  of  the  drug. 
Dryness  of  the  mouth,  thirst  and  strangury  are  occasional  untoward  symptoms. 

Treatment.  The  treatment  of  acute  poisoning  by  cannabis  indica  consists 
in  emptying  the  stomach  by  lavage  or  emetics  and  the  bowels  by  a  purge;  other- 
wise the  management  of  the  condition  is  symptomatic.  In  chronic  haschisch 
intoxication  the  use  of  the  drug  should  be  stopped.  Otherwise  the  treatment 
of  the  condition  is  symptomatic,  eliminative  and  supportive. 

COCAINISM. 

The  habitual  use  of  cocaine  is  not  at  all  infrequent.  To  it  physicians 
are  particularly  prone,  acquiring  a  desire  for  the  effects  of  the  drug  as  a  result 
of  its  employment  as  a  nasal  or  pharyngeal  application.  The  habit  may 
also  be  induced  by  the  substitution  of  cocaine  for  morphine  in  the  treatment 
of  morphinomania.  Cocainism  is  said  to  be  quite  comnion  among  the  negroes 
in  certain  parts  of  the  South.  Neurotic  individuals  are  more  susceptible  to 
this  and  other  drug  habits  than  persons  of  normal  mental  balance. 


TOBACCO    POISONING.  323 

Symptoms.  The  victim  of  cocainism  rapidly  becomes  emaciated  and  is 
subject  to  attacks  of  syncope.  Circulatory  disturbances,  a  feeble,  thready 
pulse,  insomnia,  ocular  disorders,  such  as  amblyopia,  mydriasis,  and  nystag- 
mus, mental  failure  and  delusions  not  unlike  those  of  chronic  alcoholism  may 
be  observed.  Visual  and  other  hallucinations,  usually  of  disagreeable  char- 
acter are  often  present  and  one  symptom  v^hich  is  regarded  as  typical  of  sub- 
acute or  chronic  intoxication  with  this  drug  is  a  sensation  of  crawling  worms 
or  insects  ("cocaine  bugs")  under  the  skin.  Sometimes  there  is  dehrium  or 
acute  mania.  There  seems  to  be  a  degeneration  of  the  central  nervous  system 
similar  to  that  which  occurs  in  chronic  morphinism.  The  moral  deterioration 
which  results  is  fully  as  marked  as  that  observed  in  morphinomania.  Cocaine 
is  usually  taken  by  hypodermatic  injection;  more  rarely  the  powder  itself  is 
used  as  a  snuff. 

Treatment.  Cure  is  often  difficult,  particidarly  if  the  habit  is  associated 
with  morphinism  or  alcoholism.  Relapses  are  frequent.  The  most  impor- 
tant point  in  treatment  is  the  withdrawal  of  the  drug;  it  must  be  remembered, 
however,  that  sudden  stopping  of  it  may  cause  profound  collapse.  The  result 
is  seldom  successful  unless  the  patient  is  confined  in  an  institution  for  consid- 
erable time  and  placed  under  the  care  of  competent  and  faithful  attendants. 
Tonics  and  stimulants  are  indicated  just  as  in  the  treatment  of  chronic  mor- 
phine poisoning.  Plenty  of  nourishing  food  is  necessary  and  the  nervous 
manifestations  should  be  controlled  as  in  morphinism. 

TOBACCO  POISONING. 

The  symptoms  which  result  from  the  over-use  of  tobacco  by  smoking,  chew- 
ing or  snuff  taking  are  chiefly  referable  to  the  digestive  and  nervous  systems. 
The  tongue  is  coated,  the  breath  is  foul  and  there  is  chronic  catarrh  of  the 
pharynx  and  larynx;  nausea,  vomiting,  flatulence  and  constipation  are  com- 
mon. Insomnia,  muscular  weakness,  tremors  and  even  ataxic  symptoms 
may  be  observed.  Amblyopia  and  scotoma  may  develop  and  cardiac  palpita- 
tion and  irregularity  {the  tobacco  heart),  sometimes  with  anginal  and  asthmatic 
attacks,  are  frequent.  In  prolonged  instances  the  skin  becomes  sallow  and 
the  body  emaciated. 

Treatment  consists  in  the  absolute  interdiction  of  the  tobacco;  this  may 
cause  marked  nervous  irritability  and  the  craving  for  the  drug  for  a  few  days 
is  often  very  difficult  to  withstand.  The  sleeplessness  and  nervousness  should 
be  controlled  by  the  bromides,  sulphonmethane  (sulphonal)  or  sulphon- 
ethylmethane  (trional)  and  the  cardiac  condition  may  be  relieved  as  sug- 
gested in  the  sections  upon  the  treatment  of  cardiac  irregularity  and  palpi- 
tation.    The  fluid  extract  of  cactus  grandiflorus  made  from  the  green  plant, 


224  THE    INTOXICATIONS. 

30  drops  (2.00)  thrice  daily  usually  relieves  the  latter  symptom.     Tonics  and 
nourishing  food  are  useful  adjuncts  to  the  treatment. 

The  employment  of  apomorphine  hydrochloride  in  doses  of  -g^  of  a  grain 
(0.002)  every  2  hours,  gradually  increasing  the  amount  until  nausea  is  experi- 
enced, has  been  suggested. 

CARBON  BISULPHIDE  POISONING. 

This  substance  is  employed  in  the  arts  and  especially  in  the  vulcanization 
of  rubber.  Individuals  exposed  to  its  fumes  may  become  emaciated  and 
affected  with  headache,  vertigo,  nervous  excitement,  incoordination  of  move- 
ment and  depression  of  the  special  senses  with  impairment  of  sensation  and 
motility.  Insanity  is  said  to  result  in  some  instances.  Chronic  intoxication 
may  be  evidenced  by  a  neuritis  with  paralysis  analogous  to  that  occurring  in 
plumbism. 

Carbon  disulphide,  when  directly  inhaled,  excites  violent  coughing,  and 
causes  general  anaesthesia  with  intense  muscular  rigidity.  The  drug  is  a 
powerful  heart  depressant,  and  even  in  small  doses  by  mouth  produces  severe 
nausea  and  vomiting,  with  a  burning  sensation  in  the, epigastrium,  and  a 
weak  and  rapid  heart  action. 

Treatment.  Something  may  be  done  toward  the  prevention  of  carbon 
disulphide  poisoning  by  elTecting  free  ventilation  of  the  rooms  in  which  the 
substance  is  used.  Inhalers  have  been  suggested,  but,  unless  they  are  so 
constructed  as  to  separate  the  toxic  fumes  from  the  inspired  air,  can  be  of 
little  value.  The  treatment  of  the  affection  is  wholly  symptomatic.  Phos- 
phorus may  be  employed  to  combat  the  nervous  manifestations. 

LACQUER  POISONING. 

Workers  in  lacquer,  which  is  manufactured  from  the  balsamic  gum  of 
Rhus  vernicijera,  are  subject  to  a  distressing  poisoning,  the  manifestations 
of  which  are  cutaneous.  This  form  of  intoxication  is  observed  chiefly  in 
China  and  Japan  and  occurs  both  as  a  result  of  contact  with  the  lacquer  in 
its  raw  state  and  from  inhalation  of  the  air  of  apartments  in  which  newly 
lacquered  articles  are  exposed.  The  symptoms  appear  within  a  few  hours 
after  association  with  the  poisonous  substance  and  are  evidenced  by  intense 
pruritus  of  the  skin  of  the  face,  arms  and  legs;  cutaneous  oedema  follows 
and  papules  appear  which  later  become  vesicles  containing  a  yellowish  sero- 
purulent  fluid.  Coalescence  of  the  vesicles  may  take  place.  A  rise  of  tem- 
perature is  observed  in  severe  instances.  If  the  eruption  upon  the  face  is 
intense  in  character  the  mucous  membranes  of  the  lips  and  conjunctivae  may 


FOOD    POISONING.  325 

be  involved  as  well.     The  eruption  is  said  not  to  appear  upon  the  trunk,  only 
the  face,  limbs  and  scrotum  being  subject  to  this  manifestation. 

Treatment  consists  in  the  application  of  lotions  calculated  to  allay  the 
irritation.  Of  these  lime  water  and  a  solution  of  sodium  thiosulphate, 
I  part  to  8  should  be  effective.  Dressings  of  the  national  formulary  solution 
of  alum  acetate  may  be  applied  if  the  pustulation  is  marked. 

FOOD  POISONING. 

Various  forms  of  food  when  decomposed,  contaminated  or  improperly 
prepared  may  cause  toxic  symptoms.  In  great  measure  the  symptoms  pro- 
duced are  caused  by  the  presence  of  substances  generated  in  the  decom- 
position of  organic  matter.  These  have  been  termed  ptomaines  and  occur  in 
different  types,  some  poisonous,  others  harmless;  certain  ptomaines  may  be 
innocuous  under  some  conditions  and  under  different  circumstances  markedly 
toxic. 

Meat  Poisoning  (kreotoxismus)  follows  the  ingestion  of  decomposed  flesh. 
The  most  frequent  form  is  sausage  poisoning  (botulismus  or  allantiasis)  and 
is  probably  due  to  the  employment  of  improper  methods  of  preparation.  Ham 
poisoning  sometimes  occurs  and  other  meats  have  been  known  to  cause  toxic 
symptoms.  Among  these  may  be  mentioned  beef,  veal,  mutton,  fowl,  etc. 
Cured  meats  are  responsible  at  times,  and,  while  the  tin  or  zinc  hydrochloride 
derived  from  the  cans  may  be  at  fault  occasionally,  the  meat  itself  is  often 
at  the  bottom  of  the  evil. 

Symptoms.  These  appear  after  an  interval  of  from  a  few  hours  to  a  day 
or  two  and  are  evidenced  by  the  manifestations  of  severe  gastro-intestinal 
irritation.  There  are  nausea,  vomiting,  abdominal  pain  and  diarrhoea. 
The  temperature  is  often  elevated,  and  dryness  of  the  mouth,  thirst,  dysphagia, 
headache,  dizziness,  dimness  of  sight  and  pupillary  dilatation  may  be  present; 
even  delirium  is  observed  at  times.  In  instances  which  terminate  in  death 
the  patient  passes  into  a  condition  of  collapse  with  muscular  twitchings, 
coldness  of  the  extremities  and  cardiac  and  respiratory  depression. 

Poisoning  by  Fish  (ichthyotoxismus)  and  Shell  Fish.  Certain  fish  are 
known  not  to  be  fit  for  food,  while  others,  edible  at  ordinary  times,  are  poison- 
ous during  the  spawning  season.  Diseased  or  decomposed  fish,  which  in 
its  normal  condition  and  fresh  is  good  to  eat,  may  produce  toxic  symptoms 
under  the  former  circumstances. 

Shell  fish,  particularly  mussels,  may  also  cause  poisoning.  In  the  latter 
instance  the  term  mytilotoxismus  has  been  applied  to  the  condition.  The 
poison  is  found  chiefly  in  the  liver  of  the  bivalve  and  it  is  not  known  whether 
a  certain  species  is  always  toxic  or  ordinary  mussels  become  poisonous  under 
special  circumstances. 


326  THE    INTOXICATIONS. 

Symptoms.  Fish  poisoning  is  marked  by  similar  manifestations  to  those 
of  meat  intoxication.  The  symptoms  are  often  intense  and  a  generalized 
scarlatiniform  rash  may  appear. 

Mussel  poisoning  is  evidenced  by  marked  gastro-enteric  irritation  and  fre- 
quently by  the  development  of  an  urticarial  eruption  which  may  become 
vesicular;  marked  oedema  of  the  eyelids  is  not  uncommon.  In  frequent 
instances  nervous  symptoms  such  as  convulsions,  paralysis,  delirium  and 
coma  are  observed;  death  is  not  rare  and  in  anothet  type  of  patient  may  be 
preceded  by  rapid  respiration  and  heart  action,  numbness  and  coldness  of 
the  extremities,  dilated  pupils,  and  collapse. 

Poisoning  by  Dairy  Products.  Milk  intoxication  {galactotoxismus)  may 
follow  the  ingestion  of  decomposed  milk,  and  poisoning  from  cheese  and  ice 
cream  {tyrotoxismus)  may  result  from  the  presence  of  a  ptomaine  (tyrotoxicon) 
which  has  been  isolated  by  Vaughan. 

Symptoms.  These  are  those  of  marked  gastro-intestinal  irritation  anal- 
ogous to  that  of  meat  poisoning. 

Treatment  of  Food  Intoxication.  The  first  indication  is  to  remove  the 
poisonous  substance  from  the  digestive  tract.  The  vomiting  induced  by  the 
presence  of  the  offending  food  is  usually  sufficient  to  relieve  the  stomach 
of  its  contents  but  if  not  we  should  have  recourse  to  gastric  lavage.  The 
intestine  should  be  emptied  by  repeated  fractional  doses  of  calomel  followed 
by  a  saline.  The  abdominal  cramps  may  be  relieved  by  the  application  of 
hot  water  bags  or  compresses  and  by  the  hypodermatic  injection  of  morphine 
if  necessary.  The  tendency  to  collapse  should  be  combated  by  the  hypoder- 
matic administration  of  alcohol  and  strychnine  and,  when  the  gastric  irrita- 
tion has  passed,  by  stimulants  by  mouth.  Feeding  should  be  begun  with 
care,  milk  diluted  with  one  of  the  carbonated  waters  being  first  allowed. 
The  treatment  in  other  regards  is  symptomatic. 

GRAIN  POISONING. 

The  employment  of  various  kinds  of  diseased  or  decayed  grain  as  food  is 
a  common  source  of  intoxication  in  certain  countries. 

Ergotism  occurs  among  the  lower  classes  in  Europe  where,  after  poor  har- 
vests the  indigent  are  obliged  to  use  bread  made  with  rye  contaminated  with 
the  sclerotium,  an  intermediate  stage  of  development  of  the  claviceps  purpura, 
a  fungus  which  attacks  the  rye  grain.  The  disease  is  less  common  now  than 
formerly. 

Symptoms.  Two  types  of  ergotism  are  recognized,  (i)  The  gangrenous 
form,  which  is  characterized  by  an  onset  similar  to  that  of  the  convulsive 
type,  which  is  to  be  described  in  a  later  paragraph.     In  from  a  few  days  to 


GRAIN    POISONING.  327 

a  month  a  redness,  akin  to  that  of  erysipelas,  appears  in  the  fingers,  toes  or 
upon  the  nose  or  ears.  Subsequently  a  dry  gangrene  usually  develops, 
but  in  certain  instances  the  wet  type  of  the  affection  appears.  The  process 
may  involve  an  entire  extremity  or  affect  merely  a  finger  or  toe.  The  gangrene 
is  due  to  vascular  contraction  with  stasis  of  the  blood  current  and  coagula- 
tion and  hyaline  thrombosis. 

(2)  The  convulsive  jorni.  The  difference  in  the  varieties  of  ergotism  are 
explained  by  the  different  actions  of  the  constituents  of  the  ergot  and  by  the 
fact  that  they  may  act  in  part  directly  upon  the  blood-vessels  and  in  part 
directly  upon  the  central  nervous  system.  In  some  epidemics  both  the  gan- 
grenous and  convulsive  forms  have  been  observed  but  usually  one  has  been 
much  more  prevalent  than  the  other. 

The  onset  of  the  affection  is  marked  by  anxiety  and  weariness,  gastro-in- 
testinal  irritation,  and  sometimes  by  a  slight  rise  in  temperature.  There  is  a 
sensation  of  formication,  itching  and  tingling  of  the  surface,  chiefly  on  the 
fingers  and  toes;  these  manifestations  are  followed  by  numbness  and  local 
anaesthesia.  Sometimes  anaesthesia  and  hyperaesthesia  are  found  at  the 
same  time  in  different  parts  or  even  in  the  same  part;  these  symptoms 
begin  in  the  extremities  and  spread  thence  over  the  whole  body.  The 
sensory  disturbance  may  affect  the  digestive  tract  so  that  there  may  be 
present  either  voracious  hunger  or  anorexia.  At  the  same  time  there  are 
marked  weakness  and  depression,  often  with  severe  headache  and  vertigo, 
as  well  as  central  disturbances  of  the  special  senses,  such  a?  impairment  of 
sight  and  hearing.  Convulsions  may  follow,  usually  clonic  in  character 
and  often  epileptiform;  subsequently  contractures  in  the  muscles  of  the  limbs 
and  sometimes  in  those  of  the  trunk  may  develop.  Formerly  the  disease 
was  immediately  fatal  in  a  large  proportion  of  patients  and  when  recovery 
took  place  it  was  likely  to  be  associated  with  more  or  less  loss  of  intellectual 
power  and,  in  some  instances,  with  complete  dementia. 

Treatment.  Ergotism  may  be  wholly  prevented  by  inspection  of  the  rye 
used  for  flour  and  by  destroying  all  suspicious  grain.  The  treatment  consists 
in  stopping  the  unwholesome  food  and  substituting  that  which  is  wholesome. 
The  symptoms  should  be  treated  as  indicated.  For  the  muscular  contrac- 
tures massage,  hot  bathing  and  electricity  are  useful. 

Pellagra  is  due  to  the  use  of  diseased  maize  as  a  food.  Not  only  does  the 
affection  result  from  eating  the  grain  itself  but  it  may  also  follow  the  use  of 
products  made  from  the  corn.  A  ptomaine  which  causes  analogous  symptoms 
in  animals  has  been  extracted  from  the  meal  of  diseased  maize  and  from  the 
fungi  which  affect  the  grain  a  body  which  will  also  cause  the  symptoms 
of  pellagra  has  been  isolated.  Pellagra  occurs  in  Italy,  Hungary,  Southern 
France,  Spain,  Mexico  and  Yucatan.  Adults  are  chiefly  attacked  although 
children  may  also  be  affected.     Alcoholism  is  believed  to  be  a  very  potent 


328  THE    INTOXICATIONS. 

predisposing  factor.  Poor  general  condition  and  malaria  also  predispose  to 
the  affection. 

Symptoms.  The  disease,  in  most  instances,  is  first  evidenced  by  weakness, 
malaise,  indigestion,  and  pain  in  the  head  and  back;  sleeplessness  is  common 
and  there  may  be  mental  disorder.  These  symptoms  usually  appear  in  winter 
and  with  the  appearance  of  spring  the  typical  manifestations  of  pellagra 
show  themselves.  These  consist  of  an  erythematous  eruption  which  is  fol- 
lowed by  scaling  and  wrinkling  of  the  skin,  particularly  that  of  parts  which 
are  not  covered  by  clothing;  the  usual  duration  of  the  rash  is  several  weeks, 
desquamation  then  takes  place  leaving  the  skin  thickened  and  scaly.  With 
the  cutaneous  symptoms  there  are  digestive  disorders  such  as  salivation, 
loss  of  appetite,  flatulence  and  diarrhoea.  With  the  incidence  of  summer 
amelioration  takes  place  but  there  is  a  recurrence  of  the  symptoms  with  the 
following  spring.  The  sequence  of  improvement  in  summer  and  relapses 
in  the  spring  continues  until  the  patient  becomes  affected  with  a  chronic 
cachexia  with  which  various  nervous  manifestations  are  associated;  spastic 
paralyses  of  the  lower  limbs  with  atrophy  and  contractures  occur  and  the 
deep  reflexes  are  exaggerated.  Dorsal  and  cephalic  pain,  girdle  sensations  and 
tingling  and  itching  of  the  skin  are  observed.  The  special  senses  are  impaired. 
Mental  symptoms  are  common;  the  patient  is  melancholic  and  may  attempt 
suicide,  mania  is  sometimes  noted  and  the  final  stage  of  the  affection  is  a 
permanent  dementia.  In  the  protracted  instances  of  the  disease  the  patient 
has  the  appearance  of  premature  old  age  with  marked  cachexia. 

The  prognosis  as  to  recovery  after  several  successive  attacks  is  unfavorable; 
the  course  of  the  affection  may  last  for  12  or  15  years. 

Treatment.  As  a  preventive  measure  no  diseased  corn  should  be  used 
as  food  or  in  the  manufacture  of  other  products.  A  rigid  inspection  of  all 
maize  should  be  instituted  and  suspicious  grain  should  be  destroyed,  Alcohol 
should  be  forbidden.  Strychnine  and  quinine  in  large  doses  and  especially 
arsenic  are  recommended.  The  symptoms  referable  to  the  motor  system 
necessitate  the  employment  of  hot  baths,  massage  and  electricity.  The 
affected  cutaneous  areas  should  be  anointed  with  oily  substances  to  prevent, 
if  possible,  the  thickening  and  stiffening  of  the  skin,  and  the  itching  may  be 
relieved  by  the  application  of  various  antipruritics. 

Lathyrism,  Lupinosis  or  Chick-pea  Disease  is  an  affection  due  to  the 
use  as  food  of  chick-peas  or  vetches,  particularly  the  varieties  lathyrus  sativus, 
laihyrus  cicera  and  lathyrus  clymenum.  The  peas  themselves  cause  the  disease, 
decay  being  of  no  influence  in  its  production.  The  intoxication  is  observed 
in  Italy,  France,  Algiers  and  India  where  meal  from  the  chick-pea  is  mixed 
with  the  flour  of  barley  or  wheat.  Exposure  to  cold  and  wet  is  considered 
to  be  a  predisposing  factor  in  the  causation  of  the  affection. 

Symptoms.     There  is  sometimes  a  prodromal  stage  characterized  by  gastro- 


THE    EFFECTS    OF    EXPOSURE    TO    HIGH    TEMPERATURES.  329 

intestinal  irritation  with  gastric  disturbance,  diarrhoea  and  a  rise  of  tempera- 
ture; following  this  there  is  pain  in  the  back  and  legs  with  tremors  and  weakness. 
Later  a  condition  of  spastic  paralysis,  which  may  continue  to  complete  para- 
plegia, develops.  There  are  no  disturbances  of  sensation  and  the  sphincters 
are  rarely  involved.     The  reflexes  are  increased.     The  arms  are  not  affected. 

Lathyrism  seldom  results  fatally  but  the  course  of  the  affection  is  pro- 
tracted and  the  paralysis  is,  as  a  rule,  permanent. 

Treatment  consists  in  the  avoidance  of  chick-pea  meal  as  a  food  and  in  the 
employment  of  means  calculated  to  relieve  the  symptoms.  Strong  counter- 
irritation  over  the  lumbar  region  is  recommended. 

Atryplicism  is  the  term  applied  to  poisoning  resulting  from  eating  the 
coast  orach.  In  China  the  atriplex  augustissima  and  the  atriplex  serrata 
are  used  by  the  natives  as  food,  either  raw  or  cooked  in  dough.  The  intoxi- 
cation is  characterized  by  the  appearance,  within  12  to  24  hours,  of  numb- 
ness, coldness  and  tingling  in  the  fingers  and  dorsa  of  the  hands.  Pruritus 
and  cedema  follow  and  spread  to  the  elbow.  Later  the  face  is  affected.  The 
symptoms  persist  for  several  days  and  are  followed  by  desquamation.  In 
marked  instances  vesicles  which  may  ulcerate  appear  and  gangrene  of  the 
fingers  has  been  observed.  The  resemblance  of  this  condition  to  erythromel- 
algia  has  been  remarked. 

Treatment.  The  offending  substance  should  be  removed  from  the  intes- 
tinal tract  by  inducing  free  movements  of  the  bowels.  The  local  manifes- 
tations may  be  relieved  by  the  application  of  soothing  lotions. 

THE  EFFECTS  OF  EXPOSURE  TO  HIGH  TEMPERATURES. 

HEAT  EXHAUSTION. 

Definition.  A  condition  of  prostration  characterized  by  a  tendency  to 
syncope,  vaso-motor  paralysis  and  subnormal  temperature  and  resulting  from 
over-exertion  under  high  temperature.  Exposure  to  the  direct  rays  of  the 
sun  is  unnecessary  in  the  production  of  this  affection  since  it  may  be  due  to 
the  influence  of  artificial  heart,  such  as  that  of  the  stoke-holes  of  steamships. 
It  may  occur  in  infants  during  hot  weather. 

Symptoms.  These  consist  of  intense  bodily  weakness  and  in  the  more 
marked  instances,  of  syncope,  pallor,  vertigo,  impairment  of  vision,  and  cold- 
ness of  the  surface.  There  is  a  clammy  perspiration.  The  unconscious- 
ness which  often  results  is  usually  followed  by  sleep  from  which  the  patient 
wakes  within  an  hour  or  two  in  a  normal  condition. 

In  intense  instances  the  collapse  is  more  marked,  the  heart  action  is  de- 
pressed, the  perspiration  continues  and  is  accompanied  by  restlessness  and 
even  delirium.     The  temperature  may  fall  as  low  as  95°  F.  (35°  C). 


330 


THE    INTOXICATIONS. 


Heat  exhaustion  is  easily  differentiated  from  true  sun-stroke  by  the  fact 
that  in  the  former  condition  the  bodily  temperature  is  below  the  normal, 
In  an  ordinary  attack  of  fainting  the  drop  in  temperature  is  less  extreme. 

Treatment.  The  patient  should  be  placed  upon  his  back  with  the  head 
only  slightly,  if  at  all,  elevated.  Stimulation  may  be  administered  by  mouth 
or,  if  the  condition  necessitates  its  more  immediate  action,  hypoderfnatically. 
The  diffusible  stimulants  are  to  be  preferred,  alcohol  and  ammonium  usually 
being  quickly  available;  strychnine  also  may  be  employed.  For  the  lowered 
temperature  frictions  should  be  instituted  and  hot-water  bags  or  hot  com- 
presses should  be  applied  to  the  body  and  extremities. 

SUN-STROKE. 

Synonyms.     Thermic  Fever;  Insolation;  Siriasis;  Coup  de  Soldi. 

Definition.  A  condition  caused  by  exposure  to  extremes  of  heat  and  char- 
acterized by  prostration  and  high  fever. 

JEtiology.  Sun-stroke  is  common  in  the  United  States  during  the  hot 
months  among  those  whose  occupations  necessitate  prolonged  exposure  to 
the  rays  of  the  sun  or  who  are  employed  under  shelter  where  the  temperature 
is  markedly  high,  as  in  the  fire-rooms  of  steamers,  bakeries,  sugar  refineries, 
laundries,  etc.     Soldiers  on  the  march  are  frequent  sufferers. 

Alcoholic  individuals  and  those  of  plethoric  habit  seem  especially  prone 
to  the  affection.  The  infectious  origin  of  sun-stroke  has  been  suggested  upon 
the  ground  that  it  occurs  in  epidemics  in  certain  localities  and  more  particu- 
larly in  those  unaccustomed  to  extraordinary  temperatures. 

Pathology.  The  genesis  of  thermic  fever  is  explained  upon  the  ground 
that  when  exposed  to  the  effects  of  high  temperature  the  heat  center  is  so 
affected  that  it  cannot  rid  the  organism  of  the  rapidly  accumulating  heat. 
As  a  result  of  this  impairment  of  the  elimination  of  heat  the  body  temperature 
rises.  Finally  the  heat  center  becomes  exhausted  in  its  effort  to  control  heat 
production  or  paralyzed  by  the  action  of  the  excessive  temperature  already 
reached;  all  at  once  the  tissues  begin  to  form  heat  with  great  rapidity,  the 
bodily  temperature  suddenly  rises  and  the  organism  is  overwhelmed. 

After  death  the  body  retains  its  heat  for  a  considerable  time;  rigor  mortis 
and  decay  occur  rapidly  and  the  blood  seldom  coagulates.  There  is  universal 
venous  congestion,  this  being  particularly  marked  in  the  cerebrum  and  lungs. 
The  left  ventricle  of  the  heart  is  contracted  and  the  right  is  in  a  condition  of 
dilatation.  There  may  be  parenchymatous  degeneration  of  the  liver  and 
kidneys. 

Symptoms.  The  initiatory  manifestations  are  usually  a  sensation  of  in- 
tense heat,  headache,  vertigo,  oppression  and  sometimes  nausea,  vomiting 
and  diarrhoea.     Colored  vision  {chromatopsia)  may  be  experienced.     Uncon- 


SUN-STROKE.  33I 

sciousness  with  marked  restlessness  and  even  delirium  may  follow.  The 
skin  is  flushed,  hot  and  dry>  the  temperature  ranges  from  104°  to  112°  F. 
(40°  to  44°  C.)  or  even  higher,  the  pulse  is  rapid  and  full,  the  respiration 
difficult  and  perhaps  stertorous.  There  is  pupillary  dilatation  in  the  early 
.stages,  later  contraction  is  present.  In  most  instances  the  muscles  are  re- 
laxed, but  twitchings  or  even  epileptiform  convulsions  are  sometimes  observed. 
Perspiration  may  reappear  as  a  late  symptom  but  has  no  influence  in  lessening 
the  height  of  the  temperature.  The  urine  is  diminished  and  may  contain 
albumin.  In  favorable  instances  a  fall  in  the  bodily  temperature  is  accom- 
panied by  a  remission  of  the  other  symptoms.  Complete  recovery  may 
ensue  or  the  patient  may  be  left  with  nervous  and  mental  disturbances  varying 
from  simple  loss  of  memory  to  insanity.  A  common  sequel  is  an  inability 
to  endure  even  slight  degrees  of  heat;  individuals  possessing  this  idiosyncrasy 
may  become  very  uncomfortable  at  as  low  a  temperature  as  80°  F.  (26.7°  C). 

In  fatal  sun-stroke  the  temperature  remains  high,  the  unconsciousness 
becomes  more  profound,  the  heart  weakens,  the  respiration  becomes  rapid 
and  shallow  and  death  supervenes,  usually  in  from  12  to  36  hours.  In 
another  type  of  the  affection  the  patient  may  die  suddenly  or  within  a  short 
time  after  the  onset  with  the  symptoms  of  cardiac  failure  such  as  rapid  and 
almost  imperceptible  pulse,  marked  dyspnoea  and  coma. 

The  ^'continued  thermic  jever,"  Florida  fever,"  ''country  fever"  or  " fievre 
inflammatoire"  which  occurs  in  warm  and  tropical  climates  is  a  continued 
fever  which  has  been  attributed  to  prolonged  exposure  to  a  high  temperature 
although  of  late  its  septic  origin  has  been  suggested.  The  condition  may  be 
difficult  of  separation  from  enteric  and  malarial  fevers. 

The  prognosis  varies  with  the  type  of  the  affection;  the  milder  instances 
almost  invariably  recover  under  proper  treatment. 

Treatment.  Prevention  of  sun-stroke  consists  in  the  avoidance  of  ex- 
tremes of  heat  and  abstinence  from  alcohol,  over-eating  and  over-work; 
plenty  of  water  should  be  taken,  frequent  baths  are  advisable  and  the  clothing 
should  be  light. 

In  treating  thermic  fever  the  first  indication  is  to  lower  the  temperature 
as  rapidly  as  possible.  If  a  bath  tub  is  available  the  patient  should  be  im- 
mersed in  cool  water  and  rubbed  vigorously  with  lumps  of  ice  in  the  hands  of 
at  least  two  attendants.  If  no  tub  is  at  hand  the  patient  should  be  placed  in 
the  shade,  if  in  the  open  air,  and  cool  water  should  be  dashed  upon  him.  If 
tubbing  is  impossible  for  other  reasons  ice  water  enemata  or  the  ice  pack 
may  be  substituted  for  this  procedure;  sprinkle  baths  from  a  watering  can 
held  at  a  considerable  height  or  from  a  hose  are  often  beneficial,  probably 
from  the  stimulation  effected  by  the  impact  of  the  water  against  the  body 
as  well  as  from  the  reduction  of  temperature  which  results.  The  tempera- 
ture should  be  taken  at  frequent  intervals  and  when  it  has  reached  102°  F. 


332  THE    INTOXICATIONS. 

(38.9°  C.)  the  hydriatic  measures  should  be  stopped,  for  otherwise  the  tem- 
perature is  likely  to  fall  to  a  subnormal  level  and  collapse  may  result.  The 
patient  should  now  be  put  to  bed,  given  a  cathartic  and  catheterized  if  nec- 
essary; he  should  remain  in  bed  and  on  a  light  diet  for  a  few  days.  Subse- 
quent rises  of  temperature  may  be  controlled  by  cold  sponging  or  tub  baths 
if  necessary;  the  coal  tar  antipyretics  may  also  be  employed. 

Syncope  may  be  controlled  by  hypodermatic  injections  of  brandy  or  whis- 
key; aether,  ammonium  and  strychnine  may  also  be  employed.  Artificial 
respiration  is  sometimes  necessary. 

In  the  rapidly  fatal  instances  with  symptoms  of  asphyxia,  venesection 
should  be  performed.  Convulsions  should  be  controlled  by  chloroform 
inhalations. 

The  treatment  of  the  consequences  of  thermic  fever  is  symptomatic. 


l^ATCOTIC    STOMATITIS.  333 


CHAPTER  IV. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM  AND  PERITONAEUM. 

DISEASES  OF  THE  MOUTH  AND  TONGUE. 

Of  the  more  usual  forms  of  stomatitis,  since  the  treatment  of  all  is  practi- 
cally the  same,  mycotic  stomatitis  will  be  taken  as  a  type. 

MYCOTIC  STOMATITIS. 

Synonyms.     Thrush;  Parasitic  Stomatitis;  Sprue, 

Definition.  An  inflammation  of  the  buccal  and  pharyngeal  mucous  mem- 
branes characterized  by  whitish  deposits. 

.etiology.  The  inflammation  is  due  to  the  growth  and  development 
upon  the  lining  of  the  mouth  and  pharynx  of  a  fungus,  the  oidium  albicans 
or  the  saccharomyces.  Thrush  occurs  chiefly  in  nursing  children  and  is 
especially  predisposed  to  by  poor  physical  conditions,  unhealthy  surround- 
ings and  the  use  of  unclean  nipples  and  nursing  bottles. 

Pathology.  The  oidium  albicans  grows  upon  the  mucous  membrane  in 
the  form  of  numerous  scattered  tiny  grayish-white  spots.  These  may  coalesce 
and  form  areas  covering,  in  rare  instances,  almost  the  entire  buccal  lining  and 
involving  the  oesophagus.  Around  these  whitish  spots  is  a  reddened  areola 
and  they  are  somewhat  adherent  to  the  mucous  membrane  but  may  be 
detached,  leaving  a  surface  intact  or  eroded. 

Symptoms.  These  consist  of  the  presence  of  the  already  described  spots 
and  of  those  of  the  accompanying  physical  condition.  The  mouth  is  likely 
to  be  dry  and  should  there  be  any  doubt  about  the  diagnosis  it  can  readily 
be  assured  by  recourse  to  the  microscope. 

The  Treatment  of  Stomatitis.  Infants  in  almost  all  instances  may  be 
prevented  from  acquiring  stomatitis  by  proper  attention  to  the  cleanliness  of 
rubber  nipples,  nursing  bottles,  etc.  The  nipples  should  be  boiled  daily  in  a 
solution  of  washing  soda  and  should  be  kept  in  a  boric  acid  or  sodium  salicy- 
late solution.  The  child's  mouth  should  be  cleansed  by  means  of  the  finger 
wrapped  about  with  a  bit  of  absorbent  cotton  moistened  with  boric  acid 
solution  or  a  solution  of  baking  soda.  Such  methods  should  prevent  the 
occurrence  of  sprue.  When  the  disease  is  present  the  above  means  should  be 
employed  and  in  addition  the  lining  of  the  mouth  should  be  gently  painted 
3  or  4  times  a  day  with  a  camel's  hair  brush  dipped  in  a  i  to  3  percent. 


334        DISEASES    OF   THE   DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

solution  of  silver  nitrate,  or  a  5  percent,  solution  of  alum.  In  obstinate  instances 
it  may  be  well  to  give  the  mouth  a  few  days  complete  rest  and  feed  through 
the  nasal  tube,  at  the  same  time  employing  local  treatment  as  above. 

The  various  forms  of  stomatitis  in  adults,  including  the  mercuria'l  variety, 
should  be  treated  by  strict  attention  to  the  hygiene  of  the  mouth;  the  abuse 
of  alcohol  and  tobacco  should  be  stopped,  the  teeth  should  be  frequently 
brushed  and  otherwise  properly  cared  for.  The  frequent  use  of  mildly  anti- 
septic fluids  such  as  liquor  antisepticus,  etc.,  is  to  be  recommended.  Tincture 
of  myrrh  is  a  pleasant  mouth  wash  used  in  strength  of  2  teaspoonsful  (8.0)  to 
the  tumbler  (250.0)  of  water  and  a  saturated  solution  of  potassium  chlorate  is 
also  useful.  The.  ulcers  of  aphthous  stomatitis  may  be  painted  with  3  per- 
cent, silver  nitrate  solution  or  gently  touched  with  the  silver  nitrate  stick. 

In  the  treatment  of  the  various  forms  of  stomatitis  the  general  bodily  con- 
dition must  not  be  neglected.  Proper  food,  exercise,  fresh  air,  etc.,  should 
be  advised;  tonics,  such  as  iron,  nux  vomica,  codliver  oil  and  the  like,  may  be 
necessary. 

In  mecurial  stomatitis  the  administration  of  the  mercury  should  be  stopped 
and  treatment,  such  as  that  described  above,  instituted. 

GANGRENOUS  STOMATITIS. 

Synonyms.     Noma;  Cancrum  Oris. 

Definition.  An  inflammation  usually  affecting  the  cheek  at  the  angle  of 
the  mouth  and  spreading  outward.  It  is  characterized  by  infiltration,  followed 
by  necrosis  and  gangrene,  of  the  tissues  involved. 

.Etiology.  The  disease  is  probably  of  microbic  origin;  it  is  usually  seen 
in  young  children  who  have  been  brought  up  in  unsanitary  surroundings 
and  are  in  poor  physical  condition.  It  is  rarely  primary  but,  as  a  rule,  is 
secondary  to  attacks  of  measles,  scarlatina  or  other  acute  infectious  diseases. 

Pathology.  The  process  consists  first  of  a  brawny  infiltration  of  the  tissues, 
followed  by  a  slowly  spreading  gangrene  which  may  go  on  to  perforation  of 
the  cheek  or  involvement  of  the  jaw.  Rarely  does  the  gangrenous  tissue 
separate  spontaneously,  the  process  usually  advancing  until  terminated  by 
death. 

Symptoms.  The  first  local  manifestation  is  a  dark  spot  upon  the  lip  or 
cheek,  but  usually  the  condition  is  well  advanced  before  the  diagnosis  is  made. 
There  is  a  characteristically  foul  breath  and  the  odor  of  the  sloughing  surface 
is  often  very  foetid;  as  the  disease  advances  the  eye  or  ear  may  become  involved 
and  the  neighboring  lymph  ganglia  are  enlarged.  The  pain  of  noma  is  usu- 
ally slight. 

When  the  disease  is  well  established  in  its  course  the  temperature  is  typical 
of  sepsis,  the  pulse  rapid  and  weak,  and  the  appearance  one  of  great  prostra- 


GEOGRAPHICAL    TONGUE.  335 

tion.  There  may  be  gastro-intestinal  disturbances  due  to  the  swallowing  of 
the  discharge  from  the  inflammatory  area,  or  septic  pneumonia  due  to  its 
inhalation.  The  course  of  the  disease  is  rapid,  lasting  about  a  week  or  ten 
days.     The  mortality  is  high,  75  percent,  of  infections  ending  fatally. 

Treatment.  The  prophylaxis  of  noma  consists  in  the  proper  treatment 
of  the  ordinary  forms  of  stomatitis  and  attention  to  the  condition  of  the  mouth 
during  the  course  of  all  infectious  diseases.  The  neglect  of  this  latter  is 
inexcusable,  and  too  great  stress  cannot  be  laid  upon  the  necessity  for  the 
frequent  use  of  cleansing  and  antiseptic  solutions  upon  the  mouths  and  tongues 
of  patients  suffering  from  scarlatina,  diphtheria,  measles  and  the  other  infec- 
tions. 

Cases  of  noma  should  be  isolated  and  the  treatment  of  the  disease  itself 
must,  from  the  start,  be  most  radical.  Total  excision  of  the  inflammatory 
area  with  the  knife,  or  cauterization  by  means  of  the  Paquelin  cautery  are 
methods  which  have  been  in  common  use  and  in  a  combination  of  the  two 
we  have  the  most  efficacious  means  of  treatment.  The  excision  should  be 
performed  with  the  patient  under  a  general  anaesthetic  and  it  should 
be  extended  well  beyond  the  diseased  area.  After  excision  the  cautery 
should  be  applied  to  the  edges  of  the  wound.  The  use  of  nitric  acid  or  scrap-  ■ 
ing  away  the  diseased  tissues  is  not  to  be  recommended  when  the  more  rad- 
ical procedure  is  possible. 

The  treatment,  otherwise  than  by  operation,  consists  in  stimulation  as 
indicated,  keeping  the  sloughing  surface  and  the  mouth  cleansed  by  means 
of  antiseptic  solutions,  such  as  hydrogen  dioxide,  potassium  permanganate, 
etc.,  and  instituting  a  nourishing  diet. 

The  serum  therapeusis  of  noma  is  as  yet  not  upon  sufficiently  firm  basis 
to  be  employed  to  the  exclusion  of  surgical  measures,  although  instances  have 
been  reported  in  which  antidiphtheritic  and  antistreptococcus  serum  have 
been  used  with  favorable  results. 

GEOGRAPHICAL  TONGUE. 

Synonyms.     Pityriasis  of  the  Tongue;  Eczema  of  the  Tongue. 

This  condition  is  evidenced  by  one  or  more  grayish,  slightly  elevated  spots 
upon  the  mucous  membrane  of  the  tongue.  These  areas  may  be  of  varying 
size  and  usually  involve  only  the  dorsum  of  the  organ,  they  tend  to  spread 
peripherally,  producing  patches  which  may  unite  and,  bounded  as  they  are 
by  a  slightly  elevated  border,  have  given  rise  to  the  map-fike  appearance  known 
as  the  "geographical  tongue."  The  patches  at  times  heal  and  disappear 
but  seldom  fail  to  recur  from  time  to  time.  The  symptoms  are  not  marked, 
itching  and  burning  sensations  being,  as  a  rule,  all  that  causes  the  patient  to 
complain.     There  may  be  an  accompanying  increase  in  the  salivary  secretion. 


336         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Treatment.  The  disease  is  not  of  malignant  character  although  it  is 
difficult  of  treatment.  The  general  condition,  and  especially  the  digestion 
of  the  patient,  should  be  looked  to  and  proper  diet  and  mode  of  life  insisted 
upon.  Tonics  are  useful  in  enfeebled  conditions.  Arsenic  may  be  given 
and  the  use  of  astringent  and  antiseptic  applications  is  indicated.  Silver 
nitrate  (3  percent.),  chromic  acid  (i  percent.)  and  weak  iodine  solutions  may 
be  applied  by  means  of  a  brush,  and  mouth  washes  of  weak  boric  acid  solu- 
tion or  tincture  of  myrrh  may  be  employed. 

An  ointment  of  boric  acid  and  balsam  of  Peru  in  vaseline  has  been  recom- 
mended, and  Unna  advises  applications  of  sulphur,  either  in  the  form  of  a 
natural  water  containing  this  substance,  or,  preferably,  in  his  opinion,  washed 
sulphur  in  an  emulsion. 

LEUCOPLAKIA  BUCCALIS. 

Synonyms.  Lingual  Ichthyosis;  Lingual  Psoriasis;  Leucoplasia;  Smoker's 
Tongue;  Chronic  Superficial  Glossitis. 

Definition.  A  disease  of  the  mucous  membrane  lining  the  mouth  charac- 
terized by  whitish  patches  of  irregular  size,  which  at  times  are  thickened  and 
tend  to  fissure. 

.Etiology.  The  actual  causation  of  this  condition  is  not  known;  while- 
it  has  been  ascribed  to  syphilitic  disease  it  has  been  known  to  occur  in  non- 
luetic  individuals;  the  existence  of  mercurial  stomatitis,  excessive  smoking, 
uncleanly  buccal  and  dental  conditions  and  gastro-intestinal  diseases  seem 
to  be  predisposing  factors.  Leucoplakia  is  most  often  seen  in  males  beyond 
middle-life,  and  is  said  to  predispose  to  epithelioma. 

Symptoms.  The  first  indication  of  the  disease  is  a  hardly  noticeable 
reddish  or  bluish  patch,  which  may  be  sensitive  to  hot  or  irritating  foods. 
Very  slowly  and  gradually  the  reddish  spot  develops  into  a  rounded  or  irregular 
patch,  whitish  or  pearly  in  color.  Several  of  these,  while  small  at  their  incep- 
tion, may  coalesce  as  they  increase  in  size.  The  affected  areas  become  thick- 
ened and  stiff,  have  a  hard  surface  and  may  become  fissured.  The  dorsum 
of  the  tongue  is  most  usually  the  site  of  the  lesion  but  it  may  occur  upon  other 
parts  of  this  organ,  upon  the  lining  of  the  cheeks  or  even  upon  the  lips. 

Treatment  consists  in  establishing  a  cleanly  condition  of  the  mouth,  stop- 
ping the  use  of  tobacco,  and  proper  care  of  the  teeth.  Antiseptic  and  astrin- 
gent mouth  washes  are  indicated  and  the  patches  should  be  touched  with  a 
10  percent,  silver  nitrate  solution,  or  better  with  the  lunar  caustic,  once  every 
ten  days  or  so.  The  galvano-cautery  has  been  used  with  benefit  as  also  has 
a  20  percent,  solution  of  pure  chromic  acid.  A  paste  consisting  of  resorcinol 
4  parts,  zinc  oxide  i  part,  benzoated  lard  to  8  parts  applied  to  the  plaques 
will  cause  them  to  exfoliate  and  is  recommended  by  certain  dermatologists. 


PTYALISM.  337 

Syphilitic  treatment  accomplishes  little  in  the  treatment  of  leucoplakia 
buccalis  proper  but  when  the  diagnosis  is  in  doubt  the  employment  of  mercury 
and  the  iodides  is  indicated.  Treatment  calculated  to  correct  any  accom- 
panying digestive  or  assimilative  disorder  which  may  be  present  should  benefit 
the  buccal  condition. 

DISEASES  OF  THE  SALIVARY  GLANDS. 
PTYALISM. 

Ptyalism  or  increased  secretion  of  the  saliva  occurs  as  a  symptom  in  poison- 
ing by  mercury,  iodine,  gold  and  copper.  It  may  also  be  produced  by  jabor- 
andi,  muscarine  and  tobacco.  Excessive  salivary  secretion  is  often  a  symptom 
of  various  forms  of  stomatitis  and  in  children  may  occur  as  a  neurosis. 

The  treatment  consists  in  the  proper  management  of  the  setiologic  condi- 
tion, if  due  to  stomatitis,  and  in  the  stopping  of  whatever  drug  may  be  causative 
of  the  disturbance,  together  with  measures  calculated  to  remove  whatever 
of  the  substance  may  be  retained  in  the  system.  Such  are  the  administra- 
tion of  saUne  purges  if  the  salivation  be  due  to  mercury,  or  sodium  bicar- 
bonate if  it  be  the  result  of  iodism.  Mouth  washes,  such  as  a  saturated  solu- 
tion of  potassium  chlorate,  are  useful  and  atropine  may  be  given  with  a  view 
to  the  diminution  of  the  activity  of  the  salivary  glands. 

DRY  MOUTH. 

This  condition,  sometimes  also  called  xerostomia,  is  usually  seen  in  febrile 
conditions  but  may  occur  independently.  It  is  met  most  frequently  in  hyster- 
ical women  and  may  appear  after  nervous  shock.  The  symptoms  are  dryness 
of  the  mouth  and  a  smooth,  shining  condition  of  its  mucous  membranes  which 
are  redder  than  normal  in  color. 

The  treatment  is  that  of  the  nervous  condition,  as  a  result  of  which  the 
xerostomia  has  appeared,  and  the  use  of  mouth  washes  containing  lemon  juice. 

ACUTE  PAROTITIS. 

Infectious  parotitis  has  been  discussed  in  the  section  upon  the  infectious 
diseases. 

Inflammation  of  the  parotid  gland,  other  than  mumps,  may  occur  as  a 
complication  of  the  acute  infectious  diseases  (especially  typhoid  fever),  pneu- 
monia, pyaemia  and  syphilitic  disease;  associated  with  diseases  or  injuries 
of  the  pelvic  or  abdominal  viscera  or  genital  organs;  accompanying  neuritis 
of  the  facial  nerve  and  in  poisoning  by  sulphuric  acid.  The  inflammation, 
is  usually  the  result  of  microbic  infection  which  may  be  transmitted  through 


338        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

the  blood  current  or  directly  through  the  duct  of  the  gland.  The  parotitis 
accompanying  facial  neuritis  is  in  all  probability  the  result  of  some  vaso-motor 
abnormality.  The  symptoms  of  the  condition  are  localized  pain,  tenderness 
and  swelling.  The  salivary  secretion  may  be  increased.  Abscess  formation 
may  ensue  with  an  accompanying  temperature  of  septic  type  and  increased 
pain  and  prostration. 

Treatment  consists  in  the  attempt  to  prevent  abscess  formation  by  means 
of  leeches,  the  ice  compress  or  coil.  The  coal  tar  analgesics,  especially  anti- 
pyrine  salicylate  (salipyrine)  may  be  given  to  relieve  the  pain  and  aconite 
may  be  administered  unless  the  circulation  is  depressed  by  the  causative 
infection.  As  soon  as  abscess  formation  is  evident  an  incision  should  be 
made  and  the  pus  evacuated.  Chronic  or  subacute  inflammations  of  the 
gland,  which  may  occur  as  accompaniments  of  mercurial  or  lead  poisoning, 
in  syphilis,  or  following  acute  inflammations,  should  be  treated  by  inunctions 
of  blue  ointment,  10  percent,  ichthyol  in  vaseline,  compound  iodine  or  iodine- 
vasogen  ointment. 

LUDWIG'S  ANGINA. 

Synonyms.     Angina  Ludovici;  Cellulitis  of  the  Neck. 

This  condition  is  an  inflammation  of  the  floor  of  the  mouth  beginning  in 
or  about  the  submaxillary  gland.  It  begins  usually  on  one  side,  later  spread- 
ing to  the  other,  and  is  usually  a  complication  of  one  of  the  acute  infectious 
diseases;  rarely  it  may  be  primary.  It  is  a  pyogenic  infection  and  spreads 
through  the  tissues  of  the  floor  of  the  mouth  and  the  throat.  Sloughing 
of  the  soft  parts  or  abscess  formation  may  follow;  in  rare  instances  spon- 
taneous resolution  may  take  place. 

The  symptoms  are  pain,  tenderness  and  swelling  in  the  floor  of  the  mouth, 
later  in  the  neck,  and  dyspnoea  if  the  larynx  or  trachea  is  pressed  upon  by 
the  tumor.  (Edema  of  the  glottis  may  occur.  The  abscess  may  point  either 
externally  or  internally  and  the  constitutional  symptoms  are  those  of  pus 
infection  in  general.  The  treatment  consists  in  the  early  application  of 
leeches  or  cold  in  the  form  of  compresses  or  the  ice  coil. 

Surgical  measures  are  likely  to  be  sooner  or  later  necessary  and  consist 
in  free  incision  and  evacuation  of  the  pus. 

DISEASES  OF  THE  TONSILS  AND  PHARYNX. 
ACUTE  CATARRHAL  PHARYNGITIS. 

Synonyms.  Angina;  Sore  Throat. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane  lining 
the  pharynx. 

^Etiology.  Certain  persons  appear  to  have  a  predisposition  to  frequent 


ACUTE    CATARRHAL    PHARYNGITIS.  339 

attacks  of  sore  throat.  The  exciting  cause  is  usually  exposure  to  cold  and 
dampness,  although  the  condition  may  be  caused  by  the  inhalation  of  irrita- 
ting dust  or  vapors.  The  inflammation  often  occurs  in  individuals  of  gouty 
or  rheumatic  tendency,  and  is  frequently  associated  with  acute  inflammations 
of  the  nasal  mucous  membrane  and  tonsils. 

Pathology.  As  in  all  acute  inflammations  of  mucous  membranes,  the 
pharyngeal  lining  and  the  uvula  are  at  first  dry,  congested  and  swollen;  after 
a  number  of  hours  or  a  day  or  two  there  is  an  excessive  secretion  of  mucus 
which  may  be  either  thin  and  watery  or  thick  and  viscid. 

Symptoms.  There  is  usually  a  considerable  rise  in  temperature,  preceded 
by  chilly  feelings  and  general  pains;  the  local  symptoms  consist  first  of  a  dry- 
ness of  the  throat,  with  discomfort  or  actual  pain  on  swallowing.  If  the 
inflammation  involves  the  larynx  or  Eustachian  tubes  there  will  be  hoarseness 
and  slight  cough,  or  fulness  in  the  head  and  varying  degrees  of  impairment 
of  the  hearing.  On  examination  the  throat  is  seen  to  be  red  and  swollen; 
or  covered  by  the  excess  of  mucous  secretion.  Accompanying  the  inflam- 
mation various  tonsillar  conditions  may  be  observed. 

Treatment.  If  seen  early  the  patient  should  be  given  a  Dover's  powder, 
his  bowels  should  be  freely  opened  by  repeated  small  doses  of  calomel  (^  to 
^  a  grain — 0.016  to  0.032)  followed  by  a  saline  and  he  should  be  put  to  bed. 
The  general  bodily  pain  may  be  relieved  by  antipyrine  salicylate  (salipyrine) 
in  doses  of  10  grains  (0.66)  every  2  of  3  hours  until  efficacious.  This  drug 
wiU  have  in  addition  an  antipyretic  effect  and  the  fact  that  it  contains 
the  salicyl  radical  makes  it  especially  advantageous  in  rheumatic  patients. 
Phenyl  salicylate  in  doses  of  5  to  10  grains  (0.33  to  0.66)  every  3  or  4  hours 
and  salicin  are  also  useful  in  this  connection. 

Aconite  is  of  use  in  controlling  the  fever  and  also  benefits  the  local  condi- 
tion. The  tincture  may  be  given  in  4  minim  (0.25)  doses  every  hour  or  two 
or  4^0  of  a  grain  (0.00016)  of  aconitine  may  be  administered  every  4  hours. 
These  drugs  should  be  stopped  as  soon  as  their  physiological  effect  is  evident, 
as  manifested  by  numbness  and  tingling  of  the  fauces. 

The  pain  in  the  throat  may  be  lessened  by  the  application  of  frequently 
changed  hot  or  cold  compresses,  flax  seed  poultices  or,  in  severe  instances,  by  a 
mild  mustard  paste.  The  pharyngeal  discomfort  and  the  local  inflammation 
are  amenable  to  treatment  by  various  means  such  as  tablets  to  be  dissolved 
in  the  mouth,  gargles,  direct  applications  and  sprays.  Tablets.  I^,  potassii 
chloratis  gr.  xv  (i.o),  olei  menthge  piperitae  rr]^  iii  (0.20),  extracti  krameriae 
gr.  XV  (i.o),  extracti  glycyrrhiza^  oiss  (6.0);  fiat  massa  et  div.  in  trochiscos 
no.  XXX.  I^,  codeinae  gr.  iii  (0.20),  extracti  gambir  gr.  xx  (1.33),  extracti  glycyr- 
rhizae  5iss  (6.0);  massa  fiat  et  div.  in  trochiscos  no.  xx.  I^,  cocainae  hydro- 
chloridi  gr.  sV  (0.002),  antipyrinas  gr.  ii  (0.12),  sacchari  lactis  et  aquae 
destillatae  q.  s.,  fiat  tales  trochiscos  no.  xx.    I^,  ammonii  hydrochloridi  gr.  xx 


340         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

(1.33),  pulveris  ipecacuanhse  gr.  i  (0.065),  pulveris  capsici  gr  J  (0.015),  extract! 
glycyrrhizae  5ii  (8.0);  massa  fiat  et  div.  in  trochiscos  no.  xx;  of  any  of  the 
foregoing  tablets  one  may  be  dissolved  in  the  mouth  every  2  or  3  hours.  The 
first  formula  is  indicated  in  moderate  pharyngeal  inflammations,  the  second 
and  third,  when  pain  and  irritating  cough  are  present  and  the  fourth,  when  the 
pharynx  is  covered  with  thick  and  tenacious  secretion. 

Small  pieces  of  cracked  ice  held  and  allowed  to  dissolve  in  the  mouth  are 
agreeable  when  the  pharynx  is  dry  and  painful. 

Gargles  are  unsatisfactory  as  it  is  very  difiicult  to  reach  with  them  the  site 
of  the  inflammation  but  they  may  be  used  by  patients  to  whom  the  atomizer 
spray  is  disagreeable.     Various  sprays  may  be  prescribed. 

The  following  will  be  found  useful;  potassium  chlorate  5  grains  (0.33); 
alum  5  grains  (0.33);  tannic  acid  5  grains  (0.33)  or  tincture  of  iron  chloride 
10  drops  (0.66)  to  the  ounce  (30.0)  of  water. 

Direct  applications  by  means  of  a  camel's  hair  brush  of  (a)  equal  parts 
of  glycerin  and  tincture  of  iron  chloride,  (&)  glycerole  of  tannin  or  {c)  silver 
nitrate  10  to  15  parts  to  480  of  water,  may  be  employed. 

In  the  severe  instances  quick  relief  will  usually  follow  the  use  of  astringent 
sprays  of  which  any  of  the  following  is  applicable;  zinc  chloride  or  zinc  sul- 
phate I  part  to  24  of  liquor  antisepticus;  iron  and  ammonium  sulphate  6  parts, 
glycerite  of  tannic  acid  6  parts;  or  silver  nitrate  i  part  to  48  parts  of  water. 
These  may  be  sprayed  into  the  throat  by  means  of  an  ordinary  atomizer,  first 
having  cleansed  the  parts  of  mucus  by  means  of  an  alkaline  solution  such  as 
dilute  liquor  antisepticus,  every  hour  or  two  during  the  acute  stage  of  the 
inflammation,  the  intervals  being  lengthened  as  recovery  progresses. 

Sprays  of  oily  solutions  such  as  oil  of  sandal  wood  i  part  or  eucalyptol 
2  parts  to  100  parts  of  liquid  albolene  are  often  soothing  to  the  dry  and  irri- 
table throat. 

An  important  adjunct  to  the  management  of  acute  pharyngitis  is  the  proper 
treatment  of  accompanying  nasal,  tonsillar  or  laryngeal  inflammations. 

ACUTE  FOLLICULAR  TONSILLITIS. 

Synonyms.  Acute  Lacunar  Tonsillitis;  Angina  Follicularis;  Ulcerative 
Tonsillitis. 

Definition.  An  acute  exudative  inflammation  characterized  by  the  appear- 
ance of  whitish-yellow  spots  upon  tonsils. 

Etiology.  The  direct  cause  of  this  condition  is  doubtless  a  microbic  infec- 
tion probably  due  to  one  of  the  commoner  pyogenic  bacteria.  It  is  prone 
to  attack  the  enlarged  tonsil,  and  the  exciting  cause  is  usually  undue  exposure. 
Some  persons  seem  predisposed  to  this  disease.  It  is  frequently  seen  in 
children. 


ACUTE    FOLLICULAR    TONSILLITIS.  34I 

Pathology.  The  tonsils  are  red,  congested  and  swollen;  their  crypts  are 
filled  with  plugs  consisting  of  mucus,  pus,  epithelium  and  bacteria.  There 
is  no  true  ulceration  but  occasionally  one  or  more  of  the  tonsillar  crypts 
becomes  the  seat  of  a  small  abscess - 

Symptoms.  These  resemble  so  closely  those  of  a  severe  acute  pharyn- 
gitis that  they  hardly  need  separate  description.  The  prostration  is  apt  to  be 
marked  and,  especially  in  children  unless  the  throat  is  carefully  examined, 
the  condition  is  likely  to  be  mistaken  for  some  more  serious  condition.  Exam- 
ination of  the  throat  reveals  swollen,  red  and  congested  tonsils  and  pharynx 
and  the  presence  upon  the  former  of  the  characteristic  spots.  The  differen- 
tial diagnosis  from  true  diphtheria  is  often  impossible  without  bacterial  exami- 
nation. General  bodily  pains  and  a  febrile  movement  are,  as  a  rule, 
present. 

Treatment.  When  spots  are  seen  upon  the  tonsils  of  children  it  is  always 
wise  to  give  diphtheria  antitoxin  in  therapeutic  dosage  without  waiting  for  a 
bacterial  examination  of  the  exudate,  otherwise  valuable  time  may  be  lost. 
The  constitutional  treatment  of  the  condition  otherwise  is  practically  that 
of  an  acute  pharyngitis. 

The  application  to  the  outside  of  the  throat  of  the  local  measures  described 
upon  p.  339  is  also  in  order. 

With  regard  to  local  applications  the  use  of  an  antiseptic  spray  of  Dobell's 
solution  or  of  liquor  antisepticus  and  water  is  excellent;  in  addition  the  tonsils 
should  be  painted  with  some  astringent  or  antiseptic  such  as  Monsell's  solu- 
tion, tincture  of  iron  chloride,  tincture  of  iodine,  or  i  to  1000  mercury  bi- 
chloride solution. 

As  an  adjunct  to  the  above  treatment  one  to  two  drachms  (4.0  to  8.0)  each 
(for  an  adult)  of  tincture  of  iron  chloride  and  glycerin  should  be  slowly  swallowed 
every  hour  or  two  so  that  the  mixture  may  come  into  contact  with  the  dis- 
eased surface  and  the  patient  may  dissolve  in  his  mouth  every  3  or  4  hours  a 
pastille  containing  J^  of  a  grain  (0.002)  of  thymol,  J  of  a  grain  (0.02)  of  sodium 
benzoate  and  J  of  a  grain  (0.016)  of  saccharin.  One  of  these  is  kept  in  the 
mouth  until  it  has  lost  its  taste.  It  is  then  removed,  since  by  this  time  the 
saliva  has  become  so  impregnated  with  the  medicaments  which  it  contains 
that  in  swallowing,  these  come  in  contact  with  the  seat  of  the  inflam- 
mation. 

When  adenoids  and  hypertrophy  of  the  tonsils  exist  the  removal  of  these 
as  a  prophylactic  measure  is  strongly  to  be  advised.  It  is  needless  to  say 
that  the  operation  should  not  be  done  during  the  acuity  of  the  inflammation. 

Important  also  is  attention  to  the  general  condition  of  patients  disposed 
to  tonsillar  inflammations.  Proper  hygiene,  diet  and  tonic  treatment  are 
indicated.  The  exhibition  of  codliver  oil  and  the  syrup  of  iron  iodide  is 
especially  to  be  commended  in  this  connection. 


342         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

QUINSY  SORE  THROAT. 

Synonyms.  Peritonsillar  Abscess;  Phlegmonous  Tonsillitis;  Acute  Paren- 
chymatous Tonsillitis. 

Definition.  An  acute  suppurative  inflammation  of  the  tonsillar  or  peri- 
tonsillar tissue. 

^Etiology.  The  causes  of  this  condition  are  practically  identical  with  those 
of  acute  follicular  tonsillitis.  It  is  seldom  seen  in  children  or  persons  beyond 
middle  life.  Its  actual  cause  is  pyogenic  germ  infection  but  attacks  are 
often  excited  by  exposure,  and  it  is  frequent  in  individuals  possessing  hyper- 
trophied  tonsils. 

Pathology.  One  or  both  tonsfls  may  be  affected;  they  become  swollen, 
red,  painful  and  tender  and  if  pus  formation  occurs  the  induration  gradually 
becomes  less  marked  and  an  abscess  supervenes  which,  unless  opened,  may 
rupture  and  discharge  its  contents.  The  lymph  glands  of  the  neck  are  often 
enlarged  and  tender. 

Symptoms.  The  disease  is  usually  ushered  in  by  a  chill  followed  by  a 
marked  rise  in  temperature,  general  pains  and  prostration.  There  is  pain 
in  the  throat,  increased  by  swallowing  and  by  opening  the  mouth.  There 
is  tenderness  over  the  angle  of  the  jaw  and  in  the  neck.  The  voice  becomes 
nasal,  the  secretion  of 'saliva  is  increased  and  the  pain  caused  by  swallowing 
may  result  in  dribbling  from  the  mouth.  Bad  odor  upon  the  breath  and  of 
the  saliva  is  not  infrequent.  The  swelling  of  the  pharynx  may  cause  difficulty 
in  breathing;  the  pulse  is  rapid  and  bounding  and  the  temperature  curve  is 
likely  to  be  of  septic  type.  These  symptoms  last  several  days  until  the  abscess 
forms  and  bursts  or  is  relieved  by  incision.  Under  proper  treatment  the 
prognosis  is  good.  Frequent  palpation  of  the  seat  of  the  inflammation  should 
be  made  to  determine  the  presence  of  pus. 

Treatment.  Prophylaxis  consists  in  the  removal  of  hypertrophied  tonsils 
and  attention  to  nasal  or  pharyngeal  conditions.  If  there  is  any  rheumatic 
tendency  it  should  be  combated  by  the  administration  of  the  salicylates. 
At  the  beginning  of  the  attack  the  patient  should  be  put  to  bed  and  his  bowels 
freely  opened  by  means  of  repeated  small  doses  of  calomel  followed  by  a 
saline.  The  diet  should  be  of  fluids.  If  seen  early,  an  attempt  to  abort  may 
be  made  by  means  of  the  administration  of  sodium  salicylate  lo  grains  (0.66) 
every  hour  until  physiological  effect  has  become  apparent,  tincture  of  aconite 
one  minim  every  hour  until  4  doses  have  been  taken  and  a  single  dose  of  10 
grains  (0.66)  of  quinine  with  one  (0.065)  of  opium.  These  measures  may 
succeed  if  instituted  early  in  the  inflammation. 

The  pain  and  discomfort  may  be  mitigated  by  the  local  application  of  $ 
to  10  percent,  cocaine  solution,  by  frequent  application  by  means  of  the 
finger  to  the  tonsil  of  sodium  bicarbonate  and  by  the  external  use  of  cata- 


ACUTE    CESOPHAGITIS.  343 

plasma  kaolini,  hot  water  bags  or  hot  compresses.  Gargling  the  throat  with 
as  hot  water  as  can  be  borne,  the  use  of  alkaline  and  antiseptic  sprays  and 
inhalations  of  steam  may  also  relieve  the  patient's  discomfort.  Local  blood- 
letting by  means  of  punctures  (never  scarification)  with  a  slender  sharp 
pointed  knife  will  relieve  the  tension  and  reduce  the  inflammation. 

The  tonsils  should  be  frequently  felt  by  the  physician  and  as  soon  as  fluc- 
tuation is  manifest  the  abscess  cavity  should  be  freely  incised  in  the  vertical 
direction  over  the  point  of  maximum  fluctuation  and  the  pus  evacuated. 
After  incision  the  use  of  antiseptic  gargles  an.d  sprays  should  be  continued 
until  all  inflammation  has  subsided. 

In  rare  instances  where  the  dyspnoea  due  to  the  swelling  of  the  pharynx 
and  consequent  closure  of  its  opening  is  extreme,  tracheotomy  may  become 
necessary. 

DISEASES  OF  THE  (ESOPHAGUS. 
ACUTE  CESOPHAGITIS. 

Definition.  An  acute  inflammation  of  the  oesophageal  mucosa  and  sub- 
mucosa,  rarely  involving  the  muscular  coats. 

.Etiology.  Acute  oesophageal  inflammation  is  usually  the  result  of  the 
swallowing  of  caustic  or  very  hot  liquids,  or  of  the  presence  of  foreign  bodies. 
The  eruptions  of  the  various  exanthemata  may  involve  the  oesophageal 
mucous  membrane  and  inflammations  of  the  throat  may  spread  downward 
to  this  structure. 

Pathology.  There  is  more  or  less  redness  of  the  oesophageal  lining  and 
there  may  be  sloughing  and  destruction  of  tissue,  depending  upon  the  cause 
of  the  lesion;  hollow  casts  consisting  of  the  entire  lining  of  the  organ  have  been 
given  off  following  the  ingestion  of  corrosive  acids  or  alkalies.  As  healing 
progresses  the  newly  formed  scar  tissue  may  contract  and  produce  stenoses 
of  varying  degree. 

Symptoms.  These  vary  with  the  degree  of  the  inflammation.  They 
consist  of  pain  under  the  sternum  which  is  increased  upon  deglutition,  some- 
times to  such  an  extent  as  to  render  this  process  impossible.  There  may  be 
profuse  secretion  of  mucus,  which  may  be  either  raised  or  swallowed,  from 
the  inflamed  surface.  Should  the  action  of  the  cause  of  the  lesion  be  sufii- 
cient  to  erode  the  vessel  walls  there  will  be  regurgitation  of  blood  or  this  will 
appear  in  the  stools.     The  resulting  stenosis  interferes  with  swallowing. 

Treatment.  This  consists  in  putting  the  part  as  much  at  rest  as  possible. 
If  the  patient  is  able  to  swallow  liquids  only,  these  should  be  of  the  most 
soothing  character,  such  as  milk  or  arrowroot  or  other  cereal  gruels.  The 
various  demulcents  or  the  swallowing  of  cracked  ice  afford  relief  to  the  pain. 

When  swallowing  is  impossible-the  patient  must  be  fed  by  the  rectum. 


344         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

CHRONIC  CATARRHAL  CESOPHAGITIS. 

This  condition  may  exist  as  a  complication  of  chronic  endocarditis,  cirrhosis 
of  the  Uver  or  other  affections  which  result  in  venous  stasis.  The  oesophageal 
mucous  membrane  is  the  seat  of  a  chronic  catarrhal  inflammation  with  hyper- 
secretion of  mucus.  The  veins  of  the  part  may  become  dilated  and  tortuous 
and  may  rupture  with  consequent  regurgitation  of  blood. 

The  treatment  of  this  affection  consists  in  the  proper  management  of  the 
causative  condition. 

(ESOPHAGEAL  SPASM. 

Synonym.     CEsophagismus. 

.Etiology.  This  affection  is  usually  seen  in  persons  of  neurotic  or  hypo- 
chondriacal temperament  of  either  sex.  It  may  also  occur  in  insanity,  epilepsy, 
chorea  and  other  nervous  diseases. 

Symptoms.  The  spasm  is  brought  on  by  the  attempt  to  swallow  or  by  the 
thought  of  this  act.  There  is  no  history  of  any  condition  which  might  have 
caused  a  stricture  yet  the  patient  complains  of  difficulty  in  swallowing  and 
sometimes  of  painful  deglutition.  The  condition  does  not  get  worse  as  it 
usually  does  in  true  stricture  and  there  is  equal  difficulty  in  swallowing  fluids 
and  solids;  in  instances  of  long  duration,  above  the  seat  of  the  spasm  a  dilata- 
tion may  develop  with  a  consequent  catarrhal  oesophagitis.  There  is  usually 
loss  of  flesh  and  strength. 

Treatment.  This  is  usually  efficacious  and  consists,  in  addition  to  the  proper 
managing  of  the  neurotic  condition  of  the  patient  by  means  of  sedatives, 
tonics,  diet  and  regulation  of  the  mode  of  life,  in  the  passage  of  the  stomach 
tube  or  oesophageal  bougie.  This  should  be  done  slowly  and  gently.  The 
instrument  should  be  passed  into  the  oesophagus  until  it  reaches  the  seat  of 
the  spasm.  Here  it  should  be  held  and  upon  it  very  gentle  pressure  should 
be  exerted,  suddenly  the  spasm  will  give  way  and  the  bougie  or  tube  will  pass 
through.  This  should  be  done  once  or  twice  a  day.  In  conjunction  with 
the  passage  of  the  tube  it  is  often  well  to  wash  the  stomach  and  introduce 
fluid  food. 

CANCER  OF  THE  (ESOPHAGUS. 

Cancer  of  the  oesophagus  is  usually  of  the  epithelial  type  beginning  in  the 
wall  of  the  organ  and  gradually  surrounding  it;  the  growth  develops  in  hard 
masses  which  may  or  may  not  ulcerate,  and  usually  causes  a  stenosis,  above 
which  dilatation  is  likely  to  tak€  place.  The  cancerous  process  may  involve 
any  portion  of  the  tube  but  is  slightly  more  frequent  in  its  lower  portion.  It 
may  extend  to  the  adjoining  structures  and  metastases  may  be  set  up  in  the 
various  viscera;  oesophageal  cancer  is  rarely  seen  before  middle  life. 


BENIGN    STRICTURE    OF    THE    CESGPHAGUS.  345 

Symptoms.  The  first  of  these  to  attract  notice  is  dysphagia;  at  first  it 
occurs  with  sohd  food  only,  later  liquids  are  swallowed  with  difficulty  and 
finally  complete  oesophageal  obstruction  may  develop.  The  difficulty  in 
swallowing  is  accompanied  by  the  regurgitation  of  food.  There  is  often 
pain  referred  to  the  oesophageal  or  sternal  region;  this  is  especially  marked 
when  the  patient  swallows  and  may  be  present  when  the  oesophagus  is  at  rest. 
As  the  disease  progresses  the  typical  cancerous  cachexia  appears  and  its 
advancement  may  be  rapid  because  of  the  difficulty  of  getting  sufficient  food 
into  the  patient's  stomach.  Examination  by  the  oesophageal  bougie  reveals 
the  presence  of  an  obstruction  and  may  cause  slight  haemorrhage. 

Treatment  consists  in  the  employment  of  means  to  prolong  the  patient's 
life.  He  should  be  fed  by  the  mouth  as  long  as  he  is  able  to  swallow  and 
afterward  rectal  feeding  must  be  employed.  The  obstruction  may  be  retarded 
in  its  tendency  to  cause  stenosis  by  the  gentle  passage  of  a  stomach  tube  from 
time  to  time.  Gastrostomy  may  be  performed  and  the  patient's  life  prolonged 
by  making  a  permanent  gastric  fistula  through  which  he  may  be  fed.  Other 
surgical  measures  are  of  little  avail.  The  use  of  radium  has  been  exploited 
and  is  worthy  of  trial.  The  metal  may  be  enclosed  in  a  tube  attached  to  a 
flexible  bougie  and  exposure  made  by  passing  the  same  to  the  site  of  the  lesion. 

BENIGN  STRICTURE  OF  THE  (ESOPHAGUS. 

.etiology.  This  condition  is  rarely  congenital.  More  frequently  is  it 
acquired.  Its  most  usual  cause  is  cicatricial  contraction  following  ulcers 
which  may  have  resulted  from  the  ingestion  of  escharotic  substances  or  from 
syphilis.  The  oesophagus  may  also  be  narrowed  as  a  result  of  pressure  of 
tumors  extraneous  to  it,  such  as  enlarged  mediastinal  glands  or  new  growths, 
aneurysms,  etc.,  and  as  a  result  of  tumors  having  their  origin  in  its  wall. 

Symptoms.  The  symptoms  of  non-malignant  stricture  of  the  oesophagus 
are  those  of  stenosis,  difficulty  in  swallowing  of  greater  or  less  degree,  and 
regurgitation.  Pain  is  sometimes  present.  Above  the  stricture  there  is 
usually  dilatation. 

Treatment  consists  in  the  gradual  dilation  of  the  stricture  by  means  of 
bougies.  If  cancer  is  present  this  must  be  done  with  great  care.  The  situa- 
tion of  the  lesion  should  be  determined  by  the  passage  of  one  of  these  instru- 
ments and  then,  by  using  sizes  successively  smaller,  the  calibre  of  the  opening 
is  ascertained.  When  this  has  been  done  the  stricture  is  dilated  by  passing 
as  large  an  instrument  as  is  possible  without  causing  too  much  pain.  At 
successive  sittings  the  bougies  used  may  be  of  larger  and  larger  sizes.  Certain 
strictures  may  be  of  such  small  diameter  that  no  bougie  can  be  passed,  in 
which  case  rectal  feeding  must  be  prescribed  and  surgical  procedures  are 
necessary.     These  consist  of  the  making  of  a  permanent  gastric  fistula  through 


346       DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

which  the  patient  may  be  fed,  or  the  performance  of  various  operations  upon 
either  the  oesophagus  itself  or  upon  the  extraneous  lesions  which  by  their 
pressure  cause  the  obstruction. 

DILATATIONS  OF  THE  CESOPHAGUS. 

These  may  be  either  fusiform,  involving  the  whole  circumference  of  the 
organ,  or  sacculated,  involving  only  a  portion  of  its  periphery. 

The  former  variety  is  usually  secondary  to  stricture  although  rarely  it 
may  occur  idiopathically.  It  may  involve  the  whole  length  of  the  tube  or 
only  a  portion.  Its  diameter  is  frequently  greatest  at  its  lowest  part;  the  wall 
of  the  tube  is  thickened  and  at  times  its  muscular  coat  is  paralyzed. 

Sacculated  dilatations  or  diverticula  are  of  two  varieties,  (i)  those  due  to 
contraction  of  some  tissue  which  as  a  result  of  inflammation  has  become 
adherent  to  the  oesophagus;  these  are  more  frequent  in  children,  are  usually 
small  and  may  be  multiple.  (2)  The  second  variety  is  usually  seen  in  adults, 
is  found  in  the  upper  part  of  the  tube  where  its  wall  is  weakest  and  is  due  to 
pressure,  exerted  by  boluses  of  food,  which  are  too  large,  or  to  traumatism, 
such  as  the  lodgment  of  a  bone.     Such  diverticula  involve  the  posterior  wall. 

Symptoms.  Those  of  the  fusiform  dilatations  are  dysphagia,  regurgita- 
tion of  food  and  at  times  vomiting.  The  patient  may  complain  that,  though 
a  considerable  quantity  of  food  is  eaten,  there  is  a  sensation  as  if  very  little 
reached  the  stomach. 

The  diverticula  due  to  contraction  are  usually  without  symptoms  but 
those  due  to  pressure  cause  difficulty  in  swallowing  and,  as  the  sacs  become 
larger  and  catch  the  food  swallowed,  this  is  regurgitated.  At  times  there  is  a 
foul  odor  upon  the  breath  due  to  the  decay  of  food  retained  in  the  sac.  This 
form  of  dilatation  tends  to  increase  in  size  and,  as  the  enlargement  progresses, 
it  may  press  upon  the  oesophagus  and  cause  occlusion.  As  the  difficulty 
in  getting  food  into  the  patient's  stomach  increases  he  loses  flesh  and  strength 
and  may  finally  die  from  starvation.  The  diagnosis  of  the  condition  is  made 
by  the  use  of  the  bougie  and  it  must  be  carefully  differentiated  from  stricture 
without  dilatation.  This  may  be  done  by  passing  one  instrument  into  the 
sac  and  another  into  the  stomach.  At  times  it  may  be  difficult  to  pass  a  sound 
into  the  diverticulum,  but  this  may  be  more  readily  accomplished  by  the 
use  of  a  specially  constructed  sound  slightly  bent  at  its  end.    . 

Treatment  consists  in  the  dilation  of  the  stricture,  if  it  is  present,  and  by 
feeding  through  the  stomach  tube.  Rectal  feeding  may  be  found  useful 
as  an  adjunct  to  other  means.  Surgical  measures,  such  as  the  formation  of  a 
permanent  gastric  fistula,  the  relief  of  the  causative  stenosis  by  various  oper- 
ative procedures  or  the  removal  of  the  diverticula,  may  be  employed  as 
indicated. 


ACUTE    CATARRHAL    GASTRITIS.  347 

DISEASES  OF  THE  STOMACH. 
ACUTE  CATARRHAL  GASTRITIS. 

Synonyms.     Acute  Gastric  Catarrh;   Gastric  Fever;  Acute  Dyspepsia. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous  membrane 
lining  the  stomach  due  to  simple  irritation  or  occurring  as  a  resvilt  of  the 
presence  of  the  products  of  decomposing  or  fermenting  food. 

Etiology.  The  disease  may  follow  interference  with  the  hepatic  function, 
it^  may  be  caused  by  exposure  or  it  may  complicate  any  of  the  acute  infec- 
tious diseases.  The  most  usual  causes,  however,  are  over-loading  the  stomach 
with  indigestible  or  highly  seasoned  foods  or  the  excessive  drinking  of  alco- 
holic beverages. 

Pathology.  The  gastric  mucous  membrane  becomes  first  congested  and 
swollen  and  its  secretions  are  diminished.  Later  the  mucous  secretion  is 
increased  in  quantity  and  there  may  be  an  exudation  of  serum  and  emigra- 
tion of  white  blood  cells.  More  rarely  there  may  be  small  haemorrhagic 
spots  or  haemorrhagic  erosions  upon  the  gastric  lining. 

Symptoms.  The  principal  symptoms  are  lack  of  appetite,  nausea,  usually 
followed  by  vomiting,  which  may  bring  rehef  to  the  patient,  bad  taste  in  the 
mouth  headache,  dizziness  and  general  physical  and  mental  depression. 
Pain  of  greater  or  less  degree  may  be  present. 

The  lips  and  mouth  are  dry,  the  tongue  is  coated  and  palpation  of  the 
stomach  may  reveal  indistinctly  localized  tenderness  and  distention  of  the 
organ  involved.  There  are  eructations  of  gas  and  of  acid  or  bitter  matter. 
The  vomiting  may  be  frequent  and  the  patient  sometimes  is  unable  to  keep 
anything  in  the  stomach.  The  bowels  are  usually  constipated,  though  diar- 
rhoea is  at  times  observed.  The  skin  and  conjunctivae  may  be  jaundiced  as  a 
result  of  an  accompanying  duodenitis.  There  may  be  a  moderate  febrile 
movement,  but  elevation  of  temperature  is  not  a  feature  of  this  disease. 
With  the  fever  the  pulse  is  accelerated.  The  urine  is  scanty  and  highly 
colored  and  usually  contains  urates  in  excess.  Indicanuria  is  not  infrequent. 
An  attack  of  acute  gastritis  usually  lasts  from  two  to  four  days. 

The  stomach  contents,  either  the  matter  vomited  or  the  result  of  a  test-meal, 
shows  an  abnormal  increase  in  mucus,  a  diminution  in  the  total  acidity  and 
a  lack  of  free  hydrochloric  acid.  Lactic,  but}Tic,  acetic  acids  and  bile  are 
often  present.  The  food  is  only  partially  digested  and  frequently  appears  to 
have  been  little  changed  since  it  left  the  mouth. 

Treatment.  In  persons  susceptible  to  attacks  of  acute  gastritis  much  may 
be  done  in  the  way  of  prevention  by  the  wearing  of  proper  clothing.  Con- 
striction of  the  region  of  the  stomach  by  improperly  fitting  or  too  tightly 
laced  corsets  and  especially  the  suspension  of  garments  from  the  waist  often 
predisposes  to  gastric  attacks  in  women  and  consequently  these  practices 


348       DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

should  be  inveighed  against.  Chilling  of  the  abdomen  is  likely  to  bring  on  an 
attack,  and  to  provide  against  this,  snugly  fitting  garments,  sufficiently  warm 
in  texture  and  preferably  not  open  below,  should  be  worn. 

Dietetic  prophylaxis  consists  in  the  avoidance  of  indigestible  or  highly 
seasoned  foods  and  especially  those  which  may  be  adulterated  with  chemical 
substances.  The  practice  of  food-adulteration  is  becoming  all  too  common; 
coloring  matters  and  preservatives  are  frequently  introduced  and  these  sub- 
stances are  prone  to  disturb  the  susceptible  stomach.  Not  only  must  the 
quality  of  the  ingested  food  be  supervised  but  care  should  be  exercised  against 
over-loading  the  stomach,  the  teeth  must  be  kept  in  good  condition  and  the 
patient  advised  concerning  proper  mastication  and  insalivation. 

The  treatment  of  the  attack  proper  consists  in  insuring  as  complete  rest 
as  possible  for  the  organ  involved,  consequently  it  is  wise  to  give  as  little  food 
and  drink  as  possible  until  the  gastric  irritability  has  disappeared.  There 
is  no  reason  why  the  patient  suffering  from  acute  gastritis  should  not  fast 
for  a  day  or  more,  even  though  there  is  a  sustained  prejudice  amongst  the 
laity  against  the  practice.  When  excessive  thirst  is  present  the  mouth  may 
be  rinsed  with  cool  water,  which  should  not  be  swallowed,  or  cracked  ice 
may  be  sucked.  A  little  dry  champagne,  a  weak  solution  of  hydrochloric 
acid,  carbonated  waters,  or  cold  tea  without  sugar  may  be  employed  in  check- 
ing thirst,  but  it  is  important  that  very  little  fluid  of  any  sort  should  be  taken 
at  a  time. 

After  the  day's  fast  the  first  food  to  be  allowed  is  milk;  this  may  be  di- 
luted with  a  little  lime  water  or  Vichy,  peptonized  or  boiled,  and  but  a  small 
quantity  should  be  given  at  a  time.  Beef  or  chicken  broth  containing  egg  or 
rice  may  follow  and  on  the  third  day  zwieback  or  soda  biscuit  may  be  given. 
By  the  fourth  day  the  tolerance  of  the  stomach  and  the  patient's  hunger 
will  have  so  increased  that  a  return  to  a  more  general  diet  will  be  necessary 
and  such  foods  as  calf's  brain  boiled  in  bouillon  and  broiled,  broiled  chicken 
or  squab,  broiled  sweetbreads  and  veal  boiled  in  bouillon  may  be  given; 
potato  puree  soup,  scraped  beef,  scraped  ham,  stewed  ripe  fruit,  tapioca, 
rice  and  eggs,  soft  boiled,  scrambled  or  as  omelet  may  be  added  by  the 
sixth  day. 

On  the  second  day  of  the  attack  it  is  wise  to  administer  calomel  either  in 
six  quarter  grain  (0.016)  doses,  one  every  half  hour,  or  better  in  two  large 
doses  of  5  grains  (0.33)  one  at  night,  the  other  in  the  morning.  By  this  means 
any  irritating  substance  which  may  have  gotten  beyond  the  pylorus  will  be 
prevented  from  doing  further  harm  and  any  accompanying  constipation  will 
be  relieved.  The  frequent  vomiting  of  the  first  day  will  usually  interfere  with 
any  medication  by  mouth,  even  were  it  necessary.  This  vomiting  as  a  rule 
empties  the  stomach  effectually  but  should  this  not  be  the  case  and  should 
the  emesis  persist  beyond  the  endurance  of  the  patient,  gastric  lavage  with 


ACUTE    CATARRHAL    GASTRITIS.  349 

warm  water  by  means  of  the  stomach  tube  should  be  employed.  In  children 
it  is  particularly  beneficial.  Here  a  soft  rubber  catheter  of  appropriate  size 
must  be  used  and,  while  its  eye  may  be  too  small  to  allow  the  admission  of 
the  larger  food  particles,  its  introduction  will  induce  vomiting  and  the  wash 
water  poured  through  it  will  cleanse  the  stomach.  During  the  lavage 
the  patient  should  be  directed  to  change  his  position,  standing  erect,  then 
lying  on  the  back  and  each  of  his  sides  in  succession.  Changes  of  position 
are  easily  made  in  the  case  of  children  but  in  the  adult  unaccustomed  to  the 
tube  it  will  be  found  more  difficult.  The  object  of  assuming  different  postures 
is  to  permit  the  lavage  to  cleanse  every  portion  of  the  stomach.  A  drachm 
(4.0)  of  sodium  bicarbonate  added  to  each  quart  (litre)  of  the  water  used 
will  assist  in  dissolving  the  mucus  from  the  gastric  lining.  When  the  water 
returns  clear  a  final  washing  with  a  disinfectant  solution  of  thymol  8  grains 
(0.5),  boric  acid  ^  ounce  (15.0)  to  the  quart  (litre)  of  water  is  advisable.  As 
a  substitute  for  washing  the  stomach  copious  draughts  of  warm  water  may 
be  taken  and  emesis  induced  by  applying  the  finger  to  the  pharynx.  The 
use  of  emetic  drugs  is  considered  inadvisable  by  most  gastrologists  because 
of  the  depression  and  increased  gastric  irritation  which  they  produce. 
However  one  may,  if  necessary,  give  a  drachm  (4.0)  of  syrup  of  ipecac  to  a 
child;  in  the  adult  the  hypodermatic  use  of  apomorphine  hydrochloride  j^ 
of   a  grain  (0.005)  is  to  be  preferred  to  ipecac  or  antimony. 

A  few  hours  after  the  stomach  has  been  cleansed  the  high  colonic  irrigation 
consisting  of  a  gallon  (4  litres)  of  warm — 105-110°  F.  (40.5-43.3°  C.) — 
half  saturated  boric  acid  solution  should  be  given  in  order  to  remove  any 
irritating  substance  which  may  be  present;  in  asthenic  patients  this  procedure 
acts  also  as  a  stimulant  of  considerable  value. 

Very  persistent  vomiting  is  extremely  exhausting  to  the  patient  and  when 
not  relieved  by  emptying  the  stomach  by  lavage,  may  be  controlled  by  bismuth 
and  cocaine  in  combination. 

In  rare  instances  weakness  and  tendency  to  collapse  occur  and  may  be  com- 
bated by  small  doses,  J  to  i  drachm  (2.0  to  4,0),  of  iced  champagne  or 
brandy  and  cracked  ice  repeated  as  indicated. 

Pain  or  feeling  of  oppression  in  the  abdomen  may  be  relieved  by  hot  or 
cold  applications  or  turpentine  stupes.  When  fever  is  present  the  cold  are 
to  be  preferred;  if  the  patient  is  chilly  the  hot  are  indicated. 

The  use  of  morphine  hypodermatically  for  the  pain  is  not  to  be  recom- 
mended except  under  exceptional  circumstances.  In  all  ordinary  instances 
this  symptom  may  be  controlled  by  codeine  by  mouth  or  combined  with  bella- 
donna in  suppositories  containing  each  a  quarter  of  a  grain  (0.016)  of  codeine 
and  an  equal  quantity  of  extract  of  belladonna.  One  of  these  may  be  used 
every  2  or  3  hours  until  the  pain  is  eased. 

Codeine  by  mouth  may  be  given  in  tablet  form  or  in  solution.     Quarter 


0^ 


O         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 


lo  half  grain '(0.016  to  0.03)  doses  may  be  taken  every  3  hours.  This  drug 
may  also  be  administered  hypodermatically  with  good  effect. 

Following  an  attack  of  acute  gastritis  the  appetite  may  be  poor;  in  such  a 
contingency  the  bitter  tonics,  condurango,  rhubarb,  etc.,  may  be  given,  either 
alone  or  with  dilute  hydrochloric  acid,  to  supply  the  lack  of  this  substance 
in  the  stomach.  Ten  drops  of  the  dilute  acid  (0.66)  may  be  given  in  a  glass  of 
water  before  or  during  meals.  The  following  prescription  is  also  useful  in 
this  connection  and  when  there  is  need  of  a  general  tonic.  I^  strychninae 
sulphatis,  gr.  ss  (0.03),  acidi  hydrochlorici  diluti,  5ss  (15.0),  fiuidextracti 
condurango,  ovi  (25.0),  syrupi  aurantii  corticis  q.s.  ad  §iv  (120.0).  Misce 
et  signa,  one  teaspoonful  in  a  wine  glass  of  water  ^  hour  before  each 
meal. 

It  should  be  remembered  that  mixtures  containing  hydrochloric  acid  should 
be  taken  through  a  tube  in  order  to  prevent  corrosion  of  the  teeth. 


CHRONIC  CATARRHAL  GASTRITIS. 

Synonyms.  Chronic  Catarrh  of  the  Stomach;  Chronic  Dyspepsia;  Chronic 
Gastric  Catarrh. 

Definition.  A  chronic  catarrhal  inflammation  of  the  mucous  membrane 
of  the  stomach,  usually  associated  with  the  hypersecretion  of  mucus  and 
abnormalities  of  the  digestive  elements  of  the  gastric  secretions. 

^Etiology.  This  condition  may  result  from  repeated  attacks  of  acute 
gastritis  or  the  complicating  gastritis  of  the  infectious  diseases.  It  follows 
the  continued  ingestion  of  too  much  or  improper  food  or  the  abuse  of  medi- 
cines, tobacco  and  alcoholic  drinks.  Conditions  which  interfere  with  the 
proper  blood  supply  of  the  organ,  such  as  chronic  endocarditis,  cirrhosis  of 
the  liver,  chronic  pulmonary  disease  and  chronic  nephritis,  often  produce 
this  affection. 

Pathology.  The  mucous  lining  of  the  stomach  is  swollen  and  congested, 
it  is  grayish  or  brownish  in  color,  may  be  ridged  and  usually  is  covered  with 
a  viscid  alkaline  mucus.  The  peptic  glands  are  first  increased  in  size, 
finally  degenerate  and  become  atrophic.  The  supporting  connective  tissue 
stroma  may  be  in  a  state  of  hyperplasia.  In  marked  instances  the  glands  may 
be  obliterated  by  this  over-growth  of  tissue.  These  changes  may  involve  the 
entire  gastric  mucosa  or  a  limited  portion  of  this  structure. 

Symptoms.  Pain  is  a  frequent  symptom  and  varies  from  a  sense  of  dis- 
comfort or  fulness  referred  to  the  stomach  to  marked  distress.  Tenderness 
may  be  present;  it  is,  as  a  rule,  diffuse.  The  appetite  is  diminished  or  lost 
and  even  the  thought  of  food  may  disgust  the  patient.  There  is  an  unpleasant 
taste  in  the  mouth,  a  coated  tongue,  nausea  and  oftentimes  vomiting.     The 


CHRONIC    CATARRHAL    GASTRITIS.  35I 

vomitus  consists  of  mucus  and  undigested  food  with,  rarely,  a  little  blood. 
Its  reaction  may  be  acid  or  not;  when  the  former  is  the  case  the  acidity  is  not 
due  to  the  presence  of  the  normal  hydrochloric  acid  of  the  stomach  but  to  that 
of  lactic,  butyric  and  acetic  acids,  resulting  from  the  fermentation  of  the 
undigested  food.  The  eructation  of  gas  is  a  frequent  symptom.  In  the 
alcoholic  type  of  the  disease  early  morning  vomiting  of  mucus — the  so-called 
water  brash — is  frequent.     The  bowels  are  likely  to  be  constipated. 

The  urine  is  scanty,  high  colored  and. contains  phosphates  or  urates  in 
excess.     Indicanuria  and  oxaluria  may  at  times  be  observed. 

The  patient  complains  of  headache  and  dizziness  and  loses  flesh  as  a  conse- 
quence of  the  lack  of  proper  digestion  and  assimilation,  he  sleeps  poorly 
and  may  be  melancholic.  A  febrile  movement  is  not  a  characteristic  of 
this  disease  and  the  pulse  rate  is  variable.  Reflex  dyspnoea  and  palpitation 
may  be  present. 

The  so-called  stomach  cough  is  probably  not  due  to  any  gastric  condition 
but  is  much  more  likely  to  be  due  to  pulmonary  tuberculosis  and  the  clinician 
should  always  be  on  the  lookout  for  beginning  apical  lesions  when  indefinite 
stomach  symptoms  are  described.  Many  such  instances  are  treated  by  the 
gastrologist  to  the  great  detriment  of  the  patient. 

The  course  of  chronic  gastric  catarrh  is  long  and  complete  recovery  hardly 
to  be  expected.  The  symptoms  can,  however,  be  held  in  abeyance  by  proper 
diet  and  treatment  and  the  patient's  usefulness  and  enjoyment  of  life  may 
continue  with  little  impairment. 

The  Stomach  Contents.  The  quantity  withdrawn  after  a  test-meal  is 
usually  considerable  and  much  mucus  is  present  unless  there  is  total  atrophy 
of  the  glandular  coat.  The  hydrochloric  acid  and  pepsin  are  deficient  and 
in  instances  of  glandular  atrophy  there  may  be  total  achylia.  Bacteria,  a  few 
blood  cells,  sarcina;  and  epithelial  cells  are  often  seen.  Usually  a  number 
of  test-meal  examinations  must  be  made  before  the  true  state  of  the  patient 
can  be  determined  with  certainty. 

Treatment.  Prophylaxis  consists  in  the  avoidance  of  the  errors  in  diet 
and  mode  of  life  that  are  likely  to  cause  this  condition.  The  food  should  be 
of  proper  quality  and  quantity,  it  should  be  eaten  at  regular  intervals,  and 
slowly  and  thoroughly  masticated.  Excessively  hot  or  cold  fluids  should  not 
be  drunk  and  the  abuse  of  alcoholic  beverages  and  tobacco  must  be  avoided. 
Proper  attention  should  be  paid  to  the  care  of  the  teeth  and,  where  these  are 
beyond  repair,  artificial  ones  should  be  provided.  The  use  of  the  tooth-brush 
after  every  meal  should  be  advised,  together  with  the  removal  of  all  food 
particles  from  between  the  teeth  by  means  of  a  wooden  tooth-pick  or  dental 
silk.  The  mouth  should  also  be  rinsed  after  eating  with  a  suitable  wash 
such  as  equal  parts  of  hydrogen  dioxide,  liquor  antisepticus,  lime  water  and 
water. 


352         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Conditions  of  the  heart,  liver  or  kidneys  to  which  gastric  congestion  is 
often  secondary  should  be  carefully  treated.  In  cardiac  lesions,  when  com- 
pensation is  likely  to  become  disttirbed,  digitalis,  either  alone  or  in  combina- 
tion with  strychnine,  should  be  prescribed.  The  digitalis  is  unlikely  to  dis- 
turb the  gastric  function  and  under  its  use  the  congestion  disappears,  and  the 
appetite  and  general  condition  improve.  If  the  drug  disturbs  the  stomach  it 
may  be  given  per  rectum,  in  the  form  of  the  infusion,  or  hypodermatically. 

Lavage.  By  this  means  we  are  able  to  remove  from  the  stomach  the 
excessive  accumulation  of  mucus  with  which  it  is  burdened  and  to  relieve 
the  organ  of  its  retained  content  of  fermenting  food.  It  is  the  mode  of  treat- 
ment par  excellence  in  gastritis  with  excessive  mucus  production  and  muscular 
atony.  In  this  form  of  the  inflammation  frequent  washings  are  necessary, 
while  in  atrophic  gastritis  with  little  production  of  mucus  the  procedure  need 
not  be  undertaken  so  often.  In  mucous  gastritis  the  frequency  of  the  lavage 
depends  upon  the  state  of  the  gastric  inflammation,  but  usually  once  a  day 
is  sufficient.  In  marked  instances  with  large  quantities  of  mucus  and  advanced 
atony  lavage  before  breakfast  and  in  the  evening  may  be  necessary.  The 
most  favorable  time  for  stomach-washing  is  in  the  evening  before  supper, 
since  at  this  time  the  stomach  has  been  quiet  since  the  noon  meal — which  in 
these  patients  should  be  the  principal  one — and  the  supper  to  be  taken  after- 
ward will  as  a  rule  be  light.  The  tube  having  been  passed,  the  mucus  may  be 
removed,  allowing  the  water  to  run  in  under  considerable  pressure,  the  patient 
being  recumbent  and  directed  to  change  his  position  from  time  to  time.  No 
mucus  may  appear  until  the  stomach  has  been  relieved  of  whatever  food  it 
may  contain  but,  after  this  has  been  washed  out,  further  lavage  will  usually 
detach  mucus  from  the  wall  of  the  organ  in  considerable  quantity.  Certain 
substances  calculated  to  dissolve  the  mucus  may  be  added  to  the  wash  water; 
among  these  may  be  mentioned  sodium  bicarbonate  (i  to  250),  lime  water 
(i  to  500),  and  sodium  chloride  (i  to  200).  Alkahne  mineral  waters  may 
also  be  employed.  If  the  stomach  contains  decomposing  and  fermenting 
food  a  final  washing  with  a  disinfectant  solution  is  indicated.  Of  these  there 
are  a  number,  such  as  o.i  percent,  salicylic  acid,  i  percent,  boric  acid,  0.6 
percent.  butjTic  acid,  i  percent,  resorcinol,  0.6  percent,  hydrochloric  acid, 
I  percent,  chloroform  water.  This  last  is  prepared  by  adding  the  chloro- 
form, shaking  the  mixture,  allowing  the  chloroform  to  settle  and  using  the 
water  poured  off. 

In  the  atrophic  form  of  chronic  gastritis,  with  little  mucus,  lavage  should 
be  employed  to  stimulate  the  stomach-lining  directly.  Decinormal  hydro- 
chloric acid  may  be  used  and,  if  stomach  analysis  shows  enzymes  to  be  still 
present,  a  solution  of  sodium  chloride  not  stronger  than  i  percent,  is  recom- 
mended. 

Drug  treatment   plays   a   less  important  part  in  the  management  of   the 


CHRONIC    CATARRHAL    GASTRITIS.  353 

aflfection  than  do  lavage  and  diet  regulation.  Of  the  drugs  likely  to  prove 
beneficial  silver  nitrate  may  be  mentioned.  It  may  be  given  by  mouth — i.o 
grain  (0.065),  to  peppermint  water  i  ounce  (30.0);  dose  ^  ounce  (15.0)  three 
times  a  day  when  the  stomach  is  empty — by  means  of  the  intra-gastric  spray 
of  a  i-iooo  solution,  or  the  organ  may  be  washed  with  a  1-2000  solution.  Bis- 
muth salts,  especially  the  subgallate  and  the  subnitrate  given  together,  often 
produce  a  good  effect.  A  powder  of  i  part  of  the  subgallate  to  3  parts  of 
the  subnitrate  may  be  prescribed,  of  which  the  dose  is  30  (2.0)  grains  3  or  4 
times  a  day,  or  this  powder  may  be  applied  directly  to  the  lining  of  the 
stomach  by  means  of  an  intra-gastric  insufflator.  The  disadvantage  of  the 
bismuth  treatment  is  its  likelihood  to  produce  constipation,  consequently 
in  connection  with  it  laxative  mineral  waters  and  diet  should  be  advised. 

In  the  management  of  symptoms  drugs  are  often  necessary.  Of  the  symp- 
toms which  are  likely  to  need  attention  pain  is  one.  Diet  and  stomach 
washing  may  be  sufficient  treatment,  but  if  the  pain  is  very  distressing  the 
patient  may  be  put  to  bed  and  hot  compresses  snould  be  applied  over  the 
stomach.  Opium  should  be  used  only  as  a  last  resort  and  may  be  adminis- 
tered hypo der mat ically  or  per  rectum. 

Vomiting  is  seldom  distressing  where  lavage  is  employed.  When  neces- 
sary, this  symptom  may  be  controlled  by  sucking  bits  of  cracked  ice,  by  iced 
champagne  taken  in  small  quantities,  and  by  intra-gastric  sprays  of  weak 
cocaine  or  menthol  solutions. 

Eructation  may  be  controlled  by  lavage  or  by  capsules  of  magnesia  ponderosa 
or  sodium  bicarbonate  with  or  without  the  admixture  of  a  little  sodium 
salicylate.  Animal  charcoal  in  doses  of  from  ten  to  twenty  grains  (0.66  to 
1.33)   is  also  useful. 

Constipation  is  a  frequent  accompaniment  of  chronic  gastritis.  It  should 
not  be  treated  by  laxatives  but  by  dietetic  means,  mineral  waters,  abdominal 
massage  and  by  irrigations,  if  necessary. 

Loss  of  appetite  may  prove  an  annoying  symptom.  It  may  be  managed 
by  various  means.  Stomach  washing  with  sodium  chloride  or  hydrochloric 
acid  solutions  and  the  administration  of  the  vegetable  bitters,  especially  con- 
durango,  nux  vomica  and  gentian,  or  of  basic  orexin  are  recommended.  This 
last  is  best  given  in  broths  in  doses  of  about  3  grains  (0.20)  before  meals. 

Artificial  digestants  are  of  very  limited  value.  The  administration  of 
pepsin  either  alone  or  with  hydrochloric  acid  does  not  increase  the  digestive 
power  but  when  there  is  lack  of  the  stomach  ferments  and  of  hydrochloric 
acid,  the  latter  should  be  supplied.  The  dilute  acid  should  be  administered 
in  doses  of  about  20  drops  (1.33)  after  meals,  well  diluted  and  taken  through 
a  glass  tube;  if  not  well  borne  the  dose  should  be  diminished  or  sodium  bicar- 
bonate and  pancreatin  in  doses  of  5  grains  (0.33)  each  should  be  substituted. 
These  are  especially  useful  in  old  chronic  instances.  By  means  of  the  pancreatin 
23 


354        DISEASES    OF   THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

and  the  alkali,  which  must  be  given  in  sufficient  quantity  to  neutralize  the  acidity 
of  the  stomach,  if  any  remains,  pancreatic  digestion  is  performed  in  the  stomach. 
Other  artificial  digestants,  of  which  there  are  a  number  on  the  market,  are  of 
little  use. 

Mineral  Waters.  The  great  benefit  that  sometimes  accrues  from  courses 
of  spa  treatment  is  probably  due  rather  to  the  rigid  regulation  of  diet  and 
mode  of  life  than  to  any  special  therapeutic  effect  of  the  mineral  waters  drunk. 
It  may  be  stated,  however,  that  in  chronic  gastritis  the  salt  and  alkaline 
waters,  as  well  as  the  alkaline-sahne  and  alkaline-hydrochloric  waters  are 
useful.  When  drunk  in  large  quantities  they  tend  to  cleanse  the  stomach 
of  its  excess  of  mucus  but  in  this  connection  they  cannot,  in  more  than  a  very 
slight  manner,  take  the  place  of  lavage.  It  would  seem  that  the  alkaline, 
alkaline-hydrochloric  and  sodium  sulphate  waters  are  likely  to  benefit  gastritis 
with  increased  or  only  sUghtly  diminished  hydrochloric  acid  while  the  alkaline 
and  saline  waters  are  useful  in  diminished  gastric  secretion.  In  decreased 
stomach  motility  with  dilatation  only  small  quantities  at  a  time  should  be 
allowed. 

General  Hygiene.  For  patients  who  have  become  weak  and  emaciated  a  rest 
cure  should  be  prescribed.  For  those  of  moderate  bodily  vigor  a  morning 
cold  tub  or  sponge,  if  there  is  good  reaction  afterward,  is  advisable.  Cleansing 
baths  of  warm  water  may  be  taken  twice  a  week.  Exercise  in  moderation 
should  be  systematically  taken.  Five  minutes'  work  with  light  wooden 
dumb-bells  or  clubs  before  breakfast,  at  noon,  and  at  bed  time,  together 
with  walking,  golf,  horseback  or  bicycle  riding  or  a  moderate  amount  of 
swimming  or  rowing,  is  an  excellent  means  of  keeping  the  muscular  system  in 
condition.  Exercises  of  the  muscles  of  the  abdomen,  such  as  those  described 
in  works  upon  physical  culture  are  important  in  all  gastric  abnormalities 
except  those  attended  by  haemorrhage. 

Electricity,  while  it  probably  has  little  or  no  effect  upon  the  secretion  or 
motility  of  the  stomach,  is  an  excellent  adjuvant  to  other  treatment  of  chronic 
gastritis.  Both  the  galvanic  and  faradic  currents  may  be  employed.  Fara- 
dism  acts  in  the  same  fashion  as  massage  and  should  be  administered  by 
applying  one  electrode  to  the  spinal  region  while  with  the  other  the  limbs, 
and  particularly  the  abdomen,  are  stroked.  Intra-gastric  electricity  with 
Einhorn's  electrode,  by  means  of  which  both  the  faradic  and  galvanic  currents 
may  be  applied,  is  useful  and  makes  an  excellent  impression  upon  the  patient. 

Massage  has  a  particularly  good  effect  in  gastritis  with  dilatation  and  atony 
and  in  patients  too  weak  to  take  proper  exercise.  Both  general  massage  and 
local  massage  over  the  abdornen  are  indicated.  The  latter  plays  an  impor- 
tant part  in  sustaining  the  tonus  of  the  abdominal  muscles,  and,  when  given 
directly  after  a  meal,  aids  the  atonic  organ  in  passing  its  contents  into  the 
intestine. 


CHRONIC    CATARRHAL    GASTRITIS.  355 

Diet  is  perhaps  the  most  important  factor  in  the  treatment  of  chronic  gas- 
tritis. No  fixed  list  of  proper  articles  of  food  can  be  given  but  each  patient 
must  be  studied  by  himself  both,  from  a  standpoint  of  his  symptoms  and  with 
a  view  to  the  chemical  findings  upon  stomach-contents  analysis.  In  pre- 
scribing a  diet  the  patient  himself  can  materially  assist  by  informing  the  phys- 
ician as  to  what  articles  of  food  agree  and  what  do  not.  At  the  beginning  of 
treatment  the  diet  should  be  light  and  easily  digestible  and,  if  the  gastric  mus- 
culature is  functionating  properly,  fluids  and  semi-fluids  should  make  up  the 
dietary  to  a  great  extent.  Oftentimes  a  patient  will  do  better  on  a  number  of 
small  meals  daily  than  on  three  large  ones.  If  the  analysis  shows  hydro- 
chloric acid  and  pepsin  to  be  present  in  considerable  quantity  we  may  give  a 
diet  containing  considerable  proteid,  but,  even  when  there  is  lack  of  secretion 
of  these  elements,  proteid  need  not  be  wholly  eliminated.  Carbohydrates  in 
which  there  is  no  admixture  of  large  amounts  of  cellulose  and  those  which  are 
not  likely  to  ferment  are  allowable  and  fat,  even  in  considerable  quantity,  is 
not  harmful. 

The  preparation  of  the  food  is  important.  Meats  and  fish  should  be  cooked 
in  a  steam  boiler  and  if  necessary  maybe  minced  before  being  served;  in  all 
cases  they  should  be  finely  divided  before  they  reach  the  patient's  mouth. 

Milk  is  an  excellent  food  but  often  patients  bear  it  ill.  In  such  instances  it 
may  be  mixed  with  other  articles  of  diet  as  puree  soups,  cereals,  etc.  When 
given  thus  it  is  usually  well  digested;  often  the  addition  to  it  of  vichy  or  lime 
water  will  render  it  less  liable  to  undergo  fermentation.  Soups  and  meat 
jellies  are  usually  well  borne  as  are  the  white  meats,  sweetbreads,  scraped 
beef  and  fish.  It  should  be  remembered  that  only  small  quantities  of  meat 
should  be  given  at  a  time.  Cereals  are  excellent  and  the  lighter  vegetables, 
potatoes,  beans,  peas,  asparagus,  etc.,  may  be  given  in  the  form  of  puree  soups, 
which  when  properly  made  are  very  appetizing.  Mashed  potatoes  are  allow- 
able and  toast  or  zwieback  is  preferable  to  plain  bread.  Stewed  ripe  fruits 
and  puddings  of  rice,  tapioca,  sago,  etc.,  may  be  given.  It  need  hardly  be 
stated  that  highly  seasoned  foods  are  out  of  place  although  a  little  mustard  or 
pepper  may  be  given  at  intervals  to  increase  the  appetite. 

Such  alcoholic  drinks  as  beer,  because  of  the  yeast  which  it  contains,  and 
spirits  should  be  avoided  and  it  is  better  in  most  instances  to  forbid  the  use 
of  fermented  beverages  entirely,  but  if  they  are  allowed,  a  pure  wine  containing 
no  tannic  acid  is  best.  Certain  instances  of  gastritis  due  to  over-indulgence  in 
alcohol  seem  to  digest  better  if  wine  is  allowed;  a  good  port,  tokai  or  malaga 
is  to  be  preferred.  If  lactic  acid  fermentation  occurs  upon  the  use  of  these 
sweet  wines  a  good  dry  champagne  may  be  substituted.  Naturally  the 
quantities  taken  should  be  small. 

Coffee  in  moderate  amount  may  be  taken,  but  tea,  on  account  of  its  consti- 
pating effect,  and  tobacco  should  be  stopped. 


356        DISEASES   OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

PHLEGMONOUS  GASTRITIS. 

Synonyms.     Suppurative  Gastritis;  Purulent  Gastritis. 

Definition.  A  rare  form  of  gastric  inflammation  characterized  by  a  diffuse 
infiltration  of  the  submucosa,  with  pus,  which  may  extend  to  the  muscular 
and  peritonaeal  coats  of  the  organ.  Occasionally  the  pus  is  localized  in  an 
abscess  cavity. 

.etiology.  This  condition  may  occur  idiopathically.  Primary  phleg- 
monous gastritis,  however,  is  very  rare,  most  instances  being  secondary  to  in- 
fectious processes,  pyaemia,  puerperal  sepsis  and  typhoid  fever,  for  example. 
The  suppurative  process  may  also  result  from  infection  of  an  ulcer  or  new 
growth  or  from  traumatism. 

Pathology.  In  the  diffuse  form  the  submucosa  of  the  pyloric  region  is 
most  likely  to  be  the  seat  of  the  process.  This  portion  of  the  wall  of  the 
stomach  is  infiltrated  with  pus  and  may  necrose;  the  other  coats  are  thickened. 
Perforations  may  take  place  through  the  mucosa  and  the  pus  may  exude  into 
the  cavity  of  the  organ.  If  there  is  abscess  formation,singIe  or  multiple  collec- 
tions of  pus  will  be  observed. 

Symptoms.  In  secondary  phlegmonous  gastritis  the  symptoms  closely 
resemble  those  of  peritonitis  with  sepsis;  there  are  usually  abdominal  pain, 
more  or  less  distinctly  localized  epigastric  tenderness,  meteorism,  vomiting — 
the  vomitus  rarely  contains  pus,  however — diarrhoea,  a  septic  temperature, 
small,  rapid  pulse  and  great  prostration.  In  patients  with  abscess  formation  a 
tumor  may  be  palpable.  If  the  disappearance  of  such  a  manifestation  is 
coincident  with  the  vomiting  of  pus,  there  is  good  ground  for  making  a  diag- 
nosis of  suppurative  inflammation  of  the  stomach.  Simple  vomiting  of  pus, 
however,  may  occur  in  other  conditions,  such  as  an  oesophageal  or  other  abscess 
which  may  have  ruptured  into  the  stomach.  Rupture  may  take  place  through 
the  wall  of  the  stomach  into  the  peritonaeal  cavity  with  the  accompanying 
symptoms  of  perforation.  The  disease  is  quickly  fatal,  almost  without  excep- 
tion. 

Treatment.  If  the  diagnosis  is  made  in  time,  surgical  treatment  offers 
some  hope  and  is  always  indicated;  otherwise  the  treatment  is  purely  symp- 
tomatic. Medication  given  by  mouth  is  ineffectual.  The  pain  may  be  less- 
ened by  sucking  cracked  ice,  applications  of  cold  to  the  epigastrium  and  by 
hypodermatic  injections  of  morphine.  Stimulants  given  hypodermatically 
and  per  rectum  are  indicated. 

TRAUMATIC  AND  TOXIC  GASTRITIS. 

Definition.  An  inflammation  of  the  stomach  caused  by  swallowing  caustic 
substances,  such  as  acids,  alkalies,  arsenic,  mercury  bichloride,  etc. 

Pathology.     The  post  mortem  appearances  differ  with  the  degree  of  the 


DIPHTHERITIC    GASTRITIS.  357 

corrosion  of  the  gastric  lining.  Marked  instances  reveal  a  dark  eschar  covered 
with  necrotic  mucous  membrane  bordered  by  an  inflamed  margin.  In  less 
severe  instances  the  cells  of  the  gastric  mucous  membrane  are  swollen,  degener- 
ated and  eroded.  There  may  be  haemorrhages  and  ulcer  formation.  The 
fundus  exhibits  the  most  marked  degree  of  irritation  for  this  region  is  reached 
first  by  ingested  substances.  In  instances  which  recover  the  healed  cicatrices 
may  contract  and  produce  deformities  of  the  organ. 

Symptoms.  These  vary  in  severity  with  the  degree  of  the  irritation,  but  as 
a  rule  there  is  marked  gastric  pain,  localized  tenderness,  vomiting  and  thirst. 
The  vomitus  often  contains  blood,  mucus  and  pieces  of  exfoliated  mucous 
membrane.  Marked  instances  are  characterized  by  an  expression  of  anxiety, 
weak,  rapid  pulse  and  symptoms  of  collapse  which  may  terminate  in  death 
within  a  few  hours. 

The  diagnosis  is  made  from  the  history,  but,  when  this  is  wanting,  eschars 
about  the  lips  and  in  the  mouth,  together  with  the  odor  of  the  breath  may 
suggest  the  causative  factor. 

Treatment  consists  in  the  administration  of  antidotes  both  chemical  and 
physiological;  the  chemical  antidotes  in  the  case  of  acids  being  alkalies, 
sodium  bicarbonate  for  instance,  and  for  alkalies  mild  acids  such  as  dilute 
vinegar.  The  irritation  may  be  soothed  by  demulcents — milk,  albumin 
water,  mucilages,  etc. — and  free  dilution  of  the  toxic  substance  by  drinking 
water  is  always  indicated.  The  collapse  necessitates  free  hypodermatic 
stimulation  by  means  of  strychnine,  alcohol,  etc.,  and  high  rectal  injections 
of  hot  black  coffee.  The  after  treatment  consists  of  rest  for  the  stomach, 
rectal  alimentation  and  the  bismuth  salts  in  large  doses. 

DIPHTHERITIC  GASTRITIS. 

This  is  a  rare  inflammation  and  may  occur  as  a  complication  of  true 
diphtheria  of  the  upper  air  passages  or  an  extension  of  throat  or  laryngeal 
Klebs-Loffler  infection  to  the  gastric  mucous  membrane.  Gastritis  with  the 
production  of  a  false  membrane  may  also  occur  as  a  complication  of  the 
various  infectious  diseases,  smallpox,  typhoid  and  typhus  fevers,  septicaemia, 
scarlatina  and  pneumonia.  The  lesion  cannot  be  diagnosticated  intra  vitam, 
and  is  therapeutically  of  no  interest. 

MYCOTIC  GASTRITIS. 

Instances  have  been  reported  of  gastric  infection  with  certain  fungi,  notably 
those  of  thrush  and  anthrax.  These  have  followed  infections  of  the  mouth; 
yeast  fimgi  also  have  been  known  to  set  up  gastric  inflammation.  Fortunately 
the  acidity  of  the  gastric  secretion  is  usually  able  to  destroy  the  swallowed 


358         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

micro-organisms  and  in  instances  in  which  lesions  of  this  variety  have  occurred 
the  gastric  functions  have  been  at  low  ebb.  The  larvae  of  the  common  house 
fly  and  other  insects  have  been  known  to  produce  inflammations  of  the  stomach, 

GASTRIC  ULCER. 

Synonyms.  Ulcer  of  the  Stomach;  Peptic  Ulcer;  Eound  Ulcer;  Embolic 
Ulcer;  Thrombotic  Ulcer;  Perforating  Ulcer,  Ulcus  Ventriculi. 

Definition.  A  loss  of  continuity  of  the  substance  of  the  mucous  lining  of 
the  stomach,  not  tending  to  heal  but  rather  to  increase  both  in  area  and  depth. 
The  acute  form  is  likely  to  spread  by  increasing  its  depth  while  the  chronic 
variety  tends  to  spread  laterally;  its  walls  usually  slope  inward  toward 
the  base  of  the  lesion  while  those  of  the  acute  type  are  more  vertical  and 
clearer  cut.  Perforation  into  a  blood-vessel  or  through  the  muscular  and 
peritonaeal  coats  of  the  organ  may  occur  in  either  type.  The  condition  is 
usually  characterized  by  gastric  pain,  digestive  disorders,  and  at  times  haema- 
temesis. 

^Etiology.  Gastric  ulcer  has  been  attributed  to  a  number  of  causes. 
The  disease  seems  to  be  rare  in  the  United  States,  but  it  is  probable  that  many 
instances  are  undiagnosticated.  It  is  most  common  in  young  adult  females. 
According  to  Hemmeter  there  are  five  chief  factors  in  the  production  of  this 
lesion,  a.  An  interference  with  the  vitality  or  resisting  power  of  the  mucous 
membrane,  h.  Increased  acidity  of  the  gastric  juice,  c.  An  altered  con- 
dition of  the  blood,     d.  Local  bacterial  infection,     e.  Local  traumatism. 

The  vitality  of  the  wall  of  the  stomach  may  be  impaired  by  local  or  general 
diseased  conditions  or  by  interference  with  the  blood  supply  of  a  particular 
area.  Thrombosis,  usually  the  result  of  disease  of  the  blood-vessels,  and 
embolism,  infective  or  non-infective,  are  the  common  causes  of  this  inter- 
ference. 

Constitutional  diseases,  such  as  the  blood  dyscrasiae,  syphilis,  tuberculosis, 
arterial  diseases  of  various  character,  malaria,  etc.,  are  to  be  considered. 

Of  bacterial  infections  the  most  common  are  those  of  tuberculosis,  typhoid 
fever  and  various  types  of  dysentery.  Other  bacteria  have  been  found  in  in- 
stances of  gastric  ulcer  and  may  exert  a  causative  influence  upon  the  condition. 
It  must  be  remembered  that  while  HCl  is  germicidal  it  does  not  destroy 
bacterial  spores  and  there  are  times  when  the  glands  which  secrete  this  acid 
are  at  rest  and  consequently  the  antiseptic  action  of  the  HCl  is  slight  or  absent. 
Hemmeter  suggests  that  the  bacteria  cause  a  primary  necrosis  and  encourage 
ulcer  formation  through  autodigestion. 

Direct  injury  and  consequent  impairment  of  the  power  of  resistance  of  the 
mucosa  may  be  the  result  of  the  traumatism  from  the  swallowing  of  various 
foreign  bodies  such  as  fish  bones,  oyster  or  nut  shells  and  the  like.     Corrosive 


GASTRIC    ULCER.  359 

poisons  and  the  ingestion  of  very  hot  Hquids  or  food  are  factors  worthy  of 
consideration  and  certain  observers  have  exploited  the  theory  that  the  fre- 
quency of  ulcer  in  those  in  whose  work  pressure  upon  the  stomach  is  exerted 
may  be  due  to  an  anaemia  of  the  organ  resulting  from  such  pressure. 

Pathology.  Ulcer  of  the  stomach  exists  by  a  large  percentage  most  often 
upon  the  posterior  wall  or  lesser  curvature  of  the  organ  and  it  is  rare  that  a 
single  lesion  is  found,  the  condition  being  usually  multiple.  The  typical 
round  punched-out  appearance  is  not  so  often  seen  as  is  the  oval  non-symmet- 
rical ulcer  with  irregular  edges.  The  edges  usually  slope  inward  since  the 
mucous  coat  of  the  organ  is  first  involved.  If  there  is  no  tendency  toward 
healing  the  lesion  progresses  through  the  muscular  coat  and  finally  perforates 
the  peritonaeum  covering  the  viscus.  The  typical  ulcerous  perforation  is 
circular  and  has  as  cleanly  cut  edges  as  if  punched  out  with  a  die,  but  as  above 
stated  this  form  is  less  often  seen  than  the  less  symmetrical  t\'pe.  During 
the  progress  of  the  lesion  the  blood-vessels  in  the  stomach  wall  may  be  eroded, 
resulting  in  haemorrhage  more  or  less  profuse  in  type.  A  healed  ulcer  leaves 
behind  a  distinct  and  typical  scar.  Accompanying  the  ulcer  there  is,  as  a 
rule,  a  complicating  gastritis. 

Symptoms.  The  most  characteristic  symptoms  of  gastric  ulcer  are:  a. 
Localized  pain.  This  is  due  to  irritation  of  the  sensory  nerves  laid  bare. 
It  is  burning  in  character,  most  marked  after  the  ingestion  of  food  and  fre- 
quently increases  during  the  process  of  digestion.  There  is  local  tenderness 
which  is  increased  on  pressure,  or  by  the  wearing  of  a  corset.  Various  other 
pains  due  to  sympathetic  neuralgias  of  the  intercostal  nerves,  of  the  left 
brachial  plexus  and  even  of  the  nerves  of  the  lower  limbs  may  be  present.  A 
point  of  tenderness,  "the  dorsal  point,"  sometimes  exists  at  the  back  to  the 
left  of  the  spinal  column  at  the  level  of  the  loth  to  the  12th  dorsal  vertebra. 

In  many  instances  there  is  an  unpleasant  biurning  sensation  in  the  region 
of  the  stomach  which  is  due  to  irritation  of  the  organ  from  its  hyperacid 
contents.  This  "  heart  burn"  may  also  be  referred  to  the  region  of  the  oesoph- 
agus. 

h.  Vomiting.  This  is  the  result  of  excessive  peristalsis  and  reverse  peris- 
talsis caused  by  the  irritation  and  increased  acidity  due  to  the  ulcer.  The 
vomiting  exercises  an  influence  favorable,  rather  than  otherwise,  over  the 
course  of  the  disease  since  the  emptying  of  the  stomach  allows  it  to  collapse, 
thus  bringing  the  edges  of  the  ulcer  into  approximation.  The  vomiting  is 
usually  followed  by  a  temporary  relief  from  pain. 

c.  Vomiting  of  blood  is  a  very  characteristic  symptom  of  gastric  ulcer 
and  is  the  result  of  erosion  of  a  blood-vessel.  If  the  haemorrhage  is  large  a 
considerable  quantity  of  dark  pure  blood  may  be  vomited,  if  small,  the  blood 
may  remain  in  the  organ,  undergo  partial  digestion  and  be  later  vomited  as 
"coffee-ground"  matter.     The  blood  resulting  from  gastric  haemorrhage  is 


360         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

frequently  not  vomited  in  toto  but  part  may  pass  through  the  intestine  and 
appear  in  the  stools  as  a  black,  tarry  matter.  Muscular  exertion  of  any 
character  may  induce  haemorrhage. 

Excessive  hydrochloric  acid  is  present  in  a  large  majority  of  instances  of  gastric 
ulcer  and  by  most  authorities  is  considered  as  a  causative  factor,  rather 
than  a  result  of  the  lesion. 

The  appetite  is  usually  normal  or  increased,  the  tongue  is  not  coated  and 
there  is  likely  to  be  excessive  thirst. 

Constipation  is  the  rule  but  a  normal  condition  of  the  bowels  may  exist, 
although  the  quantity  of  faecal  matter  is  likely  to  be  small  owing  to  the  lessened 
quantity  of  food  ingested.  The  iirine  is  hyperacid  except  after  emesis  when 
it  may  be  alkaline  because  of  the  large  amount  of  acid  suddenly  withdrawn 
from  the  body.     The  chlorides  are  diminished. 

The  blood,  except  after  haemorrhage,  when  the  number  of  red  cells  may  be 
much  diminished,  usually  shows  a  slight  decrease  in  the  number  of  the  eryth- 
roc}1;es  and  a  considerable  diminution  of  the  haemoglobin.  After  haemate- 
mesis  there  may  also  be  what  is  called  a  "post  haemorrhagic  leucocytosis." 
This  usually  disappears  within  a  few  days. 

A  distinctly  palpable  tumor  is  rarely  felt  except  in  old  lesions  with  thickened 
cicatrices  or  adhesions  to  neighboring  parts.  If  a  tumor  is  felt,  as  a  rule  it  is 
small,  smooth  of  surface  and  not  movable. 

The  ulcer  may  proceed  toward  healing  leaving  a  cicatrix  behind  when  the 
process  is  completed.  This  latter  may  contract  producing  the  hour-glass 
stomach,  or  a  stenosis  of  the  pylorus  with  consequent  dilatation  and  ptosis, 
in  accordance  with  the  original  situation  of  the  lesion,  or  it  may  undergo 
carcinomatous  degeneration. 

In  other  patients  the  ulcer  may  eat  its  way  through  the  entire  stomach  wall 
and  bring  about  a  local  peritonitis  if  adhesions  sufi&cient  to  shut  ofif  the  site 
of  the  perforation  have  formed,  or,  failing  this,  a  general  peritonitis.  Perfor- 
ation upward  through  the  diaphragm  resulting  in  pyopneumothorax  is  a  less 
frequent  complication. 

The  disease  is  variable  as  regards  its  course  but  under  proper  treatment 
95  percent,  of  instances  should  terminate  in  recovery  in  from  12  to  14 
days.  Complete  cure,  however,  should  hardly  be  claimed  until  the  patient 
has  been  without  gastric  pain  for  a  number  of  months.  Frequently  the 
excess  of  hydrochloric  acid  remains  after  recovery  has  taken  place. 

The  diagnosis  of  gastric  ulcer  by  means  of  the  test-meal  and  stomach  tube 
is  hardly  necessary,  and  the  passage  of  this  instrument,  except  by  a  skillful 
hand,  is  hardly  to  be  advised.  The  only  striking  abnormality  found  upon 
chemical  examination  of  the  stomach  contents  in  ulcer  is  an  abnormal  amount 
of  hydrochloric  acid.  Digestion  does  not  seem  to  be  delayed  in  ulcer,  but  is, 
on  the  contrary  often  accelerated. 


GASTRIC    ULCER.  361 

Howard  in  a  series  of  54  instances  of  ulcer  of  the  stomach  and  duodenum 
reports  the  following  findings.  Total  amount  of  residue:  54  percent.,  above 
normal,  17  percent.,  below  normal,  29  percent.,  within  normal  limits.  Total 
Acidity:  Plyperacidity  in  27.5  percent.,  hypoacidity  in  42.5  percent.,  within 
normal  limits,  30  percent.  Free  hydrochloric  acid.  Hyperchlorhydria  in 
only  17.6  percent.  Normal  content  of  hydrochloric  acid  in  26.4  percent. 
Hypochlorhydria  in  26.4  percent. 

Tests  for  lactic  acid  were  employed  in  43  patients  with  positive  result  in  14 
percent.,  doubtful  in  7  percent,  and  negative  in  79  percent. 

The  statement  so  positively  made  by  most  authorities  with  regard  to  exces- 
sive free  hydrochloric  acid  in  ulcer  is  hardly  borne  out  by  the  above  figures. 

Treatment.  Prophylaxis:  patients  with  increased  acidity  and  subject  to 
discomfort  and  pain  referred  to  the  stomach,  without  definite  signs  of  ulcer 
should  be  put  upon  a  simple  and  non-irritating  diet,  and  extremely  hot  or  cold 
food  or  drink  forbidden.     The  hyperacidity  should  receive  drug  treatment. 

In  the  treatment  proper  of  gastric  ulcer  the  problems  confronting  us  are: 

1.  To  encourage  healing  on  the  part  of  the  ulcer  by  a,  enforcing  as  com- 
plete rest  as  possible;  b,  protecting  it  from  irritation  by  food  and  from  other 
mechanical  injury,  and  from  irritation  from  chemical  sources;  c,  by  counteract- 
ing the  secretory  fermentive  abnormalities  taking  place  within  the  organ. 

2.  To  treat  the  distressing  symptoms  of  the  condition  as  they  may  arise. 

3.  To  maintain  the  bodily  strength  by  the  administration  of  nourishment 
per  rectum. 

A  period  of  complete  rest  in  bed  on  the  part  of  the  patient,  to  last  until  the 
gastric  pain  and  tenderness  have  disappeared,  should  be  enjoined.  Unless 
haematemesis  has  recently  occurred  or  is  anticipated,  he  may  read,  write  and 
receive  visitors  in  moderation  and  a  daily  sponge  bath,  with  or  without  alco- 
hol should  be  given. 

Gentle  massage  of  the  limbs  will  add  to  the  patient's  comfort  and  augment 
his  recuperative  power. 

In  order  to  protect  the  ulcer  from  irritation  and  to  encourage  it  toward 
healing  the  heaviest  of  the  bismuth  salts — the  subnitrate — is  administered 
in  dosage  of  90  to  120  grains  (6.0  to  8.0),  if  given  by  the  mouth,  daily.  The 
salt  possessing  the  highest  molecular  weight  is  preferable  since  it  will  be  most 
likely  to  sink  to  the  dependent  portions  of  the  stomach  and  consequently  come 
in  contact  with  the  ulcerating  surface  wherever  situated.  Fleiner,  who  has 
been  the  special  advocate  of  the  use  of  bismuth,  is  accustomed  to  administer 
the  drug  as  follows:  Before  food  is  taken  in  the  morning  the  stomach  is 
washed  until  the  washings  return  clear  and  non-acid  in  reaction;  then  through 
the  tube  2  J  to  5  ounces  (75.0  to  150.0)  of  bismuth  subnitrate,  free  from  arsenic, 
suspended  in  6  to  8  ounces  (240.0  to  300.0)  of  water  are  given.  After  the 
withdrawal  of  the   tube  the  patient  should  assume  the  recumbent  position 


362       DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM, 

and  remain  quiet,  so  that  the  mixture  may  come  into  contact  with  the  ulcer 
if  possible.  If  the  patient  is  receiving  food  by  mouth  he  may  take  his  break- 
fast within  a  half  hour.  The  bismuth  acts  not  only  as  a  non-irritant  protec- 
tive to  the  ulcerating  surface  but  favors  the  healing  of  the  lesion  by  an  anti- 
septic and  astringent  action.  It  is  said,  also,  to  decrease  the  excessive  acidity. 
Being  given  by  the  mouth  the  bismuth  is  quite  as  effective  as  through  the 
tube  and  passing  this  instrument  may  be  omitted  without  influencing  the 
efficacy  of  the  treatment.  The  insufflation  of  the  drug  in  powdered  form 
has  been  practised  but  presents  no  advantage  over  the  ordinary  method  of 
administration. 

In  the  employment  of  the  bismuth  treatment  Hemmeter  uses  one  drachm 
of  the  subgallate  (4.0)  to  three  (12.0)  of  the  subnitrate  in  a  pint  (J  litre)  of 
water.  He  previously  washes  out  the  stomach  with  a  solution  of  sodium  bi- 
carbonate ^  ounce  (15.0)  to  the  pint  (J  litre). 

The  problem  of  neutralizing  the  excessive  acidity  present  in  the  stomach 
is  often  not  met  successfully  because  the  attempt  is  not  made  according  to 
chemical  principles.  Sodium  bicarbonate,  a  drug  frequently  employed,  is 
worse  than  useless  since  its  presence  in  the  stomach  results  in  an  excess  of 
sodium  chloride  and  carbon  dioxide.  The  former  will  split  up  and  give  rise 
to  still  more  hydrochloric  acid,  while  the  latter  stimulates  peristalsis,  both 
of  which  results  are  exactly  at  variance  with  our  purpose.  The  most  effec- 
tual method  of  combating  the  hyperacidity  is  by  the  administration  of  mag- 
nesia ponderosa  in  dosage  of  10  grains  (0.66)  every  four  hours.  In  addition 
to  the  reduction  of  the  existing  hyperacidity  and  the  prevention  of  the  forma- 
tion of  additional  hydrochloric  acid  from  the  chemical  combination  resulting, 
magnesium  chloride  is  formed  which  exercises  a  favorable  influence  upon 
the  usually  co-existent  constipation. 

Numerous  other  treatments  of  gastric  ulcer  have  been  from  time  to  time 
exploited  and  among  them  may  be  mentioned  Cohnheim's  olive  oil  treatment 
which  consists  in  administering  this  substance  in  doses  of  from  i  to  4  ounces 
(30.0-120.0)  three  times  a  day,  passed  into  the  fasting  stomach,  which  has 
previously  been  washed;  as  in  the  case  of  the  bismuth  treatment  the  oil  may  be 
swallowed  without  the  use  of  the  tube.  It  would  seem,  however,  that  a  pre- 
vious lavage  would  increase  the  efficacy  of  this  treatment,  since  its  object  is 
to  allow  the  oil  to  come  into  direct  contact  with  the  ulcer  and  form  a  protec- 
tive coat  for  it.  It  is  claimed  also  that  the  oil  relieves  the  nausea  and  pain, 
diminishes  the  excessive  acidity  and  lastly  is  a  food  itself.  The  originator  of 
this  method  asserts  that  the  milder  instances  may  be  fed  by  mouth  during  the 
treatment — the  diet,  of  course,  being  properly  restricted — and  strict  rest  in 
bed  is  not  necessary. 

The  systematic  rest  and  mineral  water  treatment  advocated  by  Fox  and, 
with  certain  unimportant  modifications,  by  von  Leube  and  von  Ziemssen  is 


GASTRIC    ULCER.  363 

not  adapted  to  the  acute  instances  with  haematemesis  but,  after  the  intervention 
of  two  weeks  succeeding  such  an  occurrence,  it  may  be  pursued.  The  details 
of  the  treatment  are  as  follows;  The  patient  is  kept  in  bed,  not  even  being 
allowed  up  to  evacuate  the  bowels  and  bladder,  and  is  given  every  morning  a 
glass  of  Saratoga  Carlsbad  or  Hathorn  water  (either  of  which  has  quite  as 
beneficial  efifect  as  the  imported  Miihlbrunnen  of  the  original  treatment) 
to  which  75  to  150  grains  (5.0  to  10. o)  of  Carlsbad  sprudel  salts  (natural  or 
artificial)  have  been  added.  The  mineral  water  exerts  no  specific  action, 
but  serves  only  to  keep  the  bowels  open  and  to  lessen  the  gastric  acidity. 
Local  applications  to  the  epigastrium  of  a  flannel  compress  dipped  in  hot 
water  and  covered  with  oil-silk  are  prescribed  and  renewed  every  three  hours 
night  and  day.  The  diet  for  the  first  two  weeks  of  the  treatment  is  limited 
to  milk  and  beaten  eggs.  During  the  third  week  the  patient  is  allowed  to 
move  from  his  bed  to  a  lounge,  but  is  still  kept  very  quiet,  the  mineral  water 
is  continued,  and  toast  or  zwieback,  oysters,  broiled  fish,  sweetbreads,  calf's 
brain,  or  minces  of  very  finely  chopped  meat  may  be  allowed  in  small  amount. 
During  the  fovirth  week  vegetable  purees  of  peas,  beans,  potatoes  or  other 
vegetables,  and  stewed  fruits  are  permitted.  From  now  on  the  patient  may 
gradually  return  to  ordinary  diet  but  for  years  all  raw  fruits,  acid,  highly 
seasoned,  cold  and  hot  food  and  drinks  must  be  interdicted. 

In  connection  with  this  treatment  Hemmeter  employs  the  following  prescrip- 
tion to  assist  in  reducing  the  excessive  acidity  and  prevent  auto-digestion. 
I^  magnesiae  ponderosae,  sodii  bicarbonatis,  potassii  carbonatis,  aa,  grains 
Ixxv  (5.0);  sacchari  lactis,  drachms  viss  (26.0).  Of  this  half  a  teaspoonful 
(2.0)  is  taken  dry  on  the  tongue  every  3  hours. 

Silver  nitrate  has  been  recommended  by  Gerhardt.  According  to  his 
reports  the  distressing  symptoms  will  often  cease  directly  upon  its  adminis- 
tration, while  in  other  instances  it  has  no  influence  whatever  and  in  still  others 
it  seems  to  aggravate  the  symptoms.  He  believes  that  this  drug  is  useful 
in  patients  who  suffer  pain  when  the  stomach  is  empty,  on  account  of  its  neu- 
tralizing effect  upon  the  hydrochloric  acid.  His  method  is  to  give  this  agent 
in  doses  of  from  -jlg-  to  ^  a  grain  (0.006  to  0.03)  in  solution  several  times  in 
the  24  hours  upon  an  empty  stomach. 

Boas  considers  silver  nitrate  useful  especially  in  the  less  severe  instances  of  ulcer 
and  in  those  for  whom  it  is  impossible  to  institute  a  rest  cure.  He  starts  the 
treatment  with  §  an  ounce  (15.0)  of  a  i  grain  (0.065)  ^o  ^  ounce  (30.0)  solu- 
tion of  the  nitrate  in  peppermint  water  three  times  a  day  on  an  empty  stomach. 
Later  he  increases  the  strength  of  the  solution  to  1.2  grains  (0.07)  to  the 
ounce  (30.0)  and  still  later  to  1.6  grains  (o.i)  to  the  ounce  (30.0).  In  con- 
nection with  this  treatment  the  diet  must  be  carefully  regulated  and  the  patient 
should  remain  as  quiet  as  possible. 

Numerous  other  drugs  have  their  advocates  in  the   treatment  of  ulcer, 


364         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

among  which  may  be  mentioned  chloroform.  Stepp  considers  that  this 
agent  given  in  connection  with  bismuth — chloroform,  i  part;  bismuth  sub- 
nitrate,  3  parts,  distilled  water,  150  parts — exerts  a  favorable  influence. 

Condurango  bark,  in  the  opinion  of  Gerhardt,  acts  well  especially  in  old 
ulcers  in  poorly  nourished  patients. 

Fuchs  believes  that  the  action  of  bismuth  in  ulcer  is  not  alone  due  to  its 
neutralizing  effect  upon  the  hydrochloric  acid  and  to  the  fact  that  it  is  mechan- 
ically a  protective  but  that  the  subnitrate  is  reduced  to  an  oxyhydrate  which, 
being  dissolved,  is  absorbed  by  the  granulating  tissue  and  here  acts  specific- 
ally. It  also  increases  the  secretion  of  mucus  which  has  a  considerable 
protective  action.  Bismuthose,  a  combination  of  bismuth  and  albumin 
is  more  astringent  than  bismuth,  more  insoluble,  and  has  a  greater  acid- 
combining  power.  Eisner  reports  good  results  from  its  use.  Its  great  dis- 
advantage, however,  is  the  influence  of  its  astringency  upon  the  co-existent 
constipation.     It  is  particularly  useful  in  combating  hyperacidity. 

The  treatment  of  the  excessive  acidity  often  present  in  ulcer  has  received 
much  attention  and  various  methods  have  been  recommended  as  applicable 
to  the  reduction  of  this  manifestation.  Ewald  uses  the  alkalies  mixed  with 
powdered  rhubarb  and  sugar.  Others  advocate  the  use  of  sodium  bicarbon- 
ate, which  according  to  chemical  principles  directly  defeats  the  object  with 
which  it  is  given.  Riegel,  in  uncomplicated  instances,  advises  the  following 
formula:  I^  sodium  bicarb.,  magnesias  ponderosae,  aa,  drachms  ii  (8.0);  sac- 
char,  lactis,  drachms  iii  (12.0).  To  this  a  small  amount  of  powdered  rhubarb 
may  be  added  if  the  constipation  is  marked.  Of  this  J  teaspoonful  (2.0)  after 
meals  is  prescribed.  To  patients  in  whom  the  increased  acidity  is  continu- 
ous the  alkali  should  be  given  more  frequently  and  in  smaller  doses. 

Atropine  has  a  decided  influence  in  diminishing  the  secretion  of  the  gastric 
juice  and  consequently  it  and  belladonna  have  their  places  in  the  treatment 
of  hyperchlorhydria. 

The  treatment  of  the  pain  is  to  a  certain  extent  that  of  the  hyperchlorhydria 
since  the  former  is-the  residt  of  the  latter.  Usually  the  administration  of  anal- 
gesics is  unnecessary,  for  as  a  rule  the  pain  disappears  within  a  day  or  two  after 
the  institution  of  the  ordinary  treatment.  In  severe  instances  at  the  beginning 
the  hypodermatic  use  of  morphine  is  indicated;  however,  according  to  recent 
investigators,  this  is  likely  to  cause  an  increase  in  the  secretion  of  gastric  juice 
and  consequently  is  to  be  avoided  if  possible.  Codeine  or  its  phosphate 
are  sanctioned  by  certain  high  authorities.  Cannabis  indica,  while  acting  as  a 
hypnotic  to  a  very  slight  degree,  is  likely  to  cause  disagreeable  mental  phenom- 
ena. Strontium  bromide  is  recommended.  Orthoform  (a  methyl  asther  of 
benzoic  acid)  is  said  to  have  a  marked  effect  upon  the  pain  of  ulcer  and 
Murdoch  believes  that  gastric  pain  which  is  relieved  by  this  drug  augurs  the 
existence  of  ulcer. 


GASTRIC    ULCER.  365 

Local  applications  such  as  poultices  of  flax-seed  may  afford  relief  but  the 
Priesnitz  iimschlag — flannel  wrung  out  in  hot  water  and  covered  with  oil-silk — 
will  usually  be  found  to  act  as  well.  Sharply  localized  pain  due  to  peritonitis 
may  be  relieved  by  the  ice  bag  or  coil. 

Vomiting  seldom  needs  special  treatment  since  it  usually  ceases  upon  the 
institution  of  the  ordinary  course  of  treatment  directed  toward  the  cure  of  the 
ulcer.  If  this  symptom  continues  to  distress  the  patient  cracked  ice  may 
be  given  and  various  anti-emetics  such  as  cerium  oxalate,  grains  v  to  x  (0.30 
to  0.66),  chloretone,  grains  x  to  xv  (0.66  to  i.oo),  dilute  hydrocyanic  acid, 
minims  ii  to  vi  (0.13  to  0.4)  in  water,  chloroform,  minims  i  to  ii  (0.065  to 
0.13)  in  water,  etc.,  may  be  used. 

Hamatemesis  should  be  treated  by  absolute  rest  and  the  application  of  an 
ice  coil  to  the  epigastrium.  Cracked  ice  is  allowed  by  some  authorities, 
while  others  insist  that  nothing  shoifld  be  given  by  the  mouth.  If  the  haemor- 
rhage has  been  considerable  a  tube  should  be  very  carefully  introduced.  For 
this  a  skilled  hand  is  necessary  for  the  tube  must  be  passed  only  a  very  short 
distance  beyond  the  cardia.  A  pint  (500.0)  of  water  at  120°  F.  (48.9°  C.)  is 
now  introduced  and  allowed  to  remain.  Later  the  clots  should  be  siphoned 
out  so  as  to  allow  the  organ  to  contract  and  a  small  amount  of  water  containing 
about  ten  grains  (0.66)  of  heavy  magnesia  is  put  into  the  stomach  and  allowed 
to  remain.  Lavage  of  the  stomach  with  ice  water  has  given  good  results  in  a 
few  patients,  according  to  Ewald.  The  hypodermatic  use  of  morphine  sulphate 
in  dosage  of  |^  of  a  grain  (0.016)  will  quiet  the  patient,  relieve  the  air  hunger 
and  stimulate  the  heart  action.  Ergotal,  20  to  30  minims  (1.66  to  2.00),  hypo- 
dermatically,  is  recommended  by  Hemmeter  as  an  excellent  haemostatic.  Sub- 
cutaneous injections  of  ergotine,  5  to  10  grains  (0.33  to  0.66)  in  equal  parts  of 
glycerin  and  water,  may  be  found  effective.  Certain  authorities  mention 
hydrastis,  hamamelis  (witchhazel),  lead  acetate,  iron  chloride  and  other  haemos- 
tatic drugs  in  this  connection  but  it  is  probable  that  the  irritation  caused  by 
their  entrance  into  the  stomach  more  than  counteracts  their  power  over  the 
haemorrhage.  Adrenalin  chloride  in  doses  of  from  10  to  30  drops  (0.66  to  2.00) 
of  the  I  to  1,000  solution  given  in  a  drachm  (4.00)  of  water  has  seemed  to  act 
well  in  certain  instances  of  gastric  haemorrhage  and  it  will  be  interesting  to 
observe  the  results  of  its  administration  under  the  skin. 

Excessive  gastric  haemorrhage  with  its  accompanying  symptoms  of  heart 
weakness,  pallor,  and  general  collapse  calls  for  immediate  and  energetic  treat- 
ment. The  usual  means  employed  in  hjemorrhage  from  any  source  must  be 
instituted  at  once.  Hj^odermatic  stimulation  by  means  of  camphor  and 
aether  or  camphor  and  oil,  strychnine  sulphate,  etc.,  is  indicated.  The  so- 
called  bleeding  of  the  patient  into  his  own  tissues  which  consists  in  applying 
snug  bandages  to  the  limbs  and  thus  forcing  the  blood  into  the  trunk,  is  an 
excellent  resource  as  is  the  administration  of  copious  high  rectal  enemata 


366        DISEASES   OF   THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

of  normal  (0.9  percent.)  solution  of  sodium  chloride,  at  a  temperature  of 
105°-! 1 2°  F.  (40.4°  to  44.5°  C).  Intravenous  infusion  of  saline,  or,  what 
may  be  much  more  rapidly  performed,  the  giving  of  the  solution  under  the 
skin  of  the  fleshy  parts  of  the  back,  chest  or  thighs  may  be  advised.  For 
this  procedure  the  only  necessary  apparatus  is  a  fair  sized  aspirating  needle,  a 
few  feet  of  rubber  tube  and  a  funnel.  The  funnel  is  filled,  the  solution  al- 
lowed to  flow  through  the  tube  and  the  needle,  and  the  last  is.  plunged  into 
the  subcutaneous  tissue  of  the  part  selected.  If  the  part  is  massaged  as  the 
fluid  is  flowing  in  a  pint  (500.0)  or  more  of  the  solution  may  be  given. 

'A  necessary  precaution  in  connection  with  this  as  with  other  methods  of 
stimulation  is  to  take  care  lest  the  vascular  tension  be  raised  to  such  an  extent 
as  to  excite  further  hcemorrhage  and  thus  defeat  our  object.  The  tension 
should  be  allowed  to  remain  low  lest  this  accident  take  place. 

Feeding  in  Gastric  Ulcer.  During  the  progress  of  the  treatment  most 
approved  by  the  author — i.e.,  that  of  bismuth  subnitrate  combined  with 
heavy  magnesia — the  patient  is  fed  entirely  by  rectum.  A  nutrient  enema, 
preceded  by  a  high  rectal  irrigation  of  about  a  quart  (litre)  of  normal  saline  so- 
lution at  about  105°  F.  (40.5°  C.)  to  cleanse  the  intestinal  mucous  membrane 
and  facilitate  absorption,  is  administered  every  4  hours.  The  enema  preferred 
by  the  author  consists  of  one-half  to  one  ounce  (15.0  to  30.0)  of  starch  paste 
with  2  to  3  ounces  (60.0  to  go.o)  of  beef  extract,  liquid  peptonoids  or  pano- 
pepton. 

Rectal  feeding  should  usually  be  continued  for  about  two  weeks. 

Other  enemata  useful  in  this  disease  may  be  chosen  from  the  following 
formulae : 

1.  Milk,  4  ounces  (120.0);  the  yolks  of  two  eggs;  salt,  i  drachm  (4.0); 
claret,  i  ounce  (30.0);  aleuronat  flour,  one-half  ounce  (15.0).     (Boas.) 

2.  Two  or  three  eggs  beaten  with  a  little  water;  i  ounce  (30.0)  of  dextrinized 
flour  boiled  with  4  ounces  (120.0)  of  20  percent,  solution  of  lactose;  one  wine- 
glass (30.0)  of  claret,  a  little  salt.  The  eggs  should  not  be  mixed  with  the 
other  ingredients  until  the  latter  have  cooled  so  that  their  temperature  will 
not  coagulate  the  albumin  of  the  former. 

3.  Bouillon,  8  ounces  (240.0);  wine,  2  ounces  (60.0);  the  yolks  of  two  eggs; 
dry  peptone  i  to  5  drachms  (4.0  to  20.0).     (Jaccoud.) 

4.  Milk,  8  ounces  (240.0);  two  to  three  eggs;  a  little  salt.     (Riegel.) 

5.  Milk,  8  ounces  (240.0);  liquid  peptone,  i  ounce  (30.0);  yolk  of  one  egg; 
laudanum,  5  drops  (0.33);  a  small  quantity  of  sodium  bicarbonate  for  chem- 
ical neutralization  if  the  peptone  is  acid.     (Dujardin-Beaumetz.) 

6.  Two  eggs;  whiskey,  one-half  ounce  (15.0);  starch  paste,  one-half  ounce 
(15.0);  milk  up  to  8  ounces  (240.6). 

Other  formulae  may  be  made  up  as  occasion  requires.  In  quantity  nutrient 
enemata,  according  to  most  authorities,  should  not  exceed  3  or  4  ounces 


GASTRIC    ULCER.  367 

(90.0  to  120.0),  and  the  proper  interval  for  their  administration  is  about  every 
four  hours.     Four  enemata  during  the  24  hours  are  sufl&cient. 

When  enemata  larger  in  quantity  than  the  above  are  well  borne  it  may  be 
wise  to  give  as  a  routine  three  daily  injections  of  a  pint  (500.0)  of  food  each. 
This  procedure  relieves  the  patient  of  too  frequent  disturbance  and  allows 
his  sleep  to  be  unbroken.  The  enema  may  consist  of  the  whites  of  two  eggs, 
a  teaspoonful  (4.0)  of  salt,  ij  ounces  (45.0)  of  a  saturated  solution  of  glucose, 
and  milk  up  to  a  pint  (500.0).  Such  a  mixture  contains  carbohyhrates, 
fat,  proteid  and  salts  in  approximately  proper  proportions. 

Nutrient  enemata,  particularly  those  of  considerable  size,  are  better  given, 
from  a  fountain  S}Tinge  than  by  means  of  the  piston  variety,  since  the  force 
and  tendency  of  the  latter  to  sudden  spurts  may  cause  irritability  of  the  bowel,. 

Food  given  per  rectum  will  be  more  readily  absorbed  and  assimilated  if 
peptonized  and  not  only  the  milk  but  the  other  constituents  of  nutritive 
enemata  should  undergo  this  process.  Preparations  for  the  convenient 
peptonizing  of  food  substances  are  obtainable  at  any  apothecary's.  By  certain 
patients  the  enemata  may  not  be  well  borne  or  may  be  difficult  of  retention 
on  account  of  irritability  of  the  bowel.  Such  a  complication  may  be  obviated 
by  preliminary  cleansing  of  the  bowel  by  a  saline  enema  and,  if  this  procedure 
fails,  by  the  addition  of  a  small  dose  of  the  tincture  of  opium  to  each  enema. 

Nutrient  enemata  should  be  thoroughly  mixed  and  administered  warm. 
100°  F.  (37.8°  C),  under  moderate  pressure  and  very  slowly  through  a  soft 
rubber  rectal  tube  passed  as  high  into  the  bowel  as  possible.  Care  should 
be  taken  lest  the  tube  turn  on  itself  and  its  extremity,  instead  of  being 
in  the  sigmoid  flexure,  be  just  inside  the  anus.  The  best  position  for  the 
patient  to  assume  while  receiving  the  enema  is  upon  the  left  side.  After 
about  30  minutes  he  should  turn  to  the  right  side  and  a  pillow  should  be  placed 
under  his  hips.  These  positions  facilitate  the  flow  of  the  enema  through  the 
colon. 

At  intervals  it  may  be  necessary  to  give  a  high  enema  of  clear  water  for  the 
relief  of  the  thirst. 

After  the  cessation  of  rectal  feeding  the  return  to  ordinary  diet  must  be 
very  gradual.  The  first  foods  allowed  by  mouth  may  be  equal  parts  of  milk 
and  lime  water,  beef  bouillon,  to  which  such  substances  as  plasmon,  nutrose 
or  somatose  may  be  added,  and  albumin  water.  These  fluids  must  be  given 
at  a  neutral  temperature — neither  hot  nor  cold.  Sugar  solution  (20  percent.) 
may  also  be  allowed.  Dextrose  is  the  preferable  form  of  sugar,  but  cane  sugar 
is  allowable.  Lactose  is  least  desirable.  After  about  ten  days  a  more  liberal 
diet  may  be  instituted  consisting — according  to  von  Leube — of  boiled  sweet- 
breads, calf's  brain,  white  meat  of  chicken,  various  gruels  and  vegetable 
puree  soups,  tapioca  with  milk,  oatmeal  and  finely  scraped  raw  beef.  After 
a  week  scraped  raw  ham,  finely  chopped  rare  broiled  beef  steak,  toast  or 


368         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

zwieback,  and  mashed  potatoes  are  allowable,  as  also  are  stewed  fresh  non- 
acid  fruits.  Further  extension  of  the  diet  should  be  postponed  as  long  as 
possible,  but  when  this  becomes  necessary  the  patient  may  eat  broiled  chicken 
and  veal,  rare  roast  beef,  fish,  plain  meat  soups,  etc. 

All  irritating  foods,  such  as  vegetables  containing  an  excess  of  cellulose, 
breads  with  hard  crusts,  fruits  with  tough  skins,  together  with  alcoholic  bever- 
ages, should  be  refrained  from  until  all  the  symptoms  have  disappeared  and 
have  remained  absent  for  a  long  period  of  time.  Cold  and  hot,  sour  or  highly- 
spiced  foods  and  drinks  should  be  avoided  for  many  months  after  the  cure 
is  apparent. 

The  ansemia  so  frequently  accompanying  gastric  ulcer  should  never  be 
neglected.  To  combat  this  important  factor  in  the  disease  iron  and  arsenic 
are  our  chief  reliance.  It  is  needless  to  say  that  their  administration  should 
not  be  begun  until  all  the  symptoms  of  gastric  irritation  have  disappeared. 
Ewald  is  accustomed  to  give  a  2  or  3  percent,  solution  of  iron  sesquichloride 
three  times  a  day  in  teaspoonful  (4.0)  doses  in  an  ounce  (30.0)  of  albumin 
water.  This  should  be  taken  through  a  tube.  The  various  forms  of  organic 
iron  which  have  lately  been  put  upon  the  market  should  be  useful  in  this 
connection  particularly  iron  vitellin  in  half  ounce  (15.0)  doses  given  three 
times  daily  after  meals. 

Arsenic  may  be  given  in  the  form  of  Fowler's  solution  or  arsenic  trioxide. 
The  various  mineral  waters  containing  iron  and  arsenic  will  be  found  useful. 

The  surgical  treatment  of  gastric  ulcer  may  be  divided  into: 

a.  The  treatment  of  the  ulcer  by  excision. 

h.  The  treatment  of  haemorrhage. 

c.  The  treatment  of  perforation. 

d.  The  treatment  of  gastro-peritonseal  adhesions. 

e.  The  treatment  of  the  various  resulting  gastric  deformities  such  as 
stenosis  of  the  pylorus,  hour-glass  contraction,  etc. 

It  is  conceded  by  most  surgeons  that  acute  gastric  ulcer  is  a  medical  condi- 
tion but  chronic  ulcer  with  obstinate  and  persistent  emesis  and  pain  may  be 
treated  surgically  by  excision  or  cauterization.  In  multiple  ulcer  excision  of 
all  the  ulcerating  points  is,  however,  impossible.  Ulcers  situated  near  the 
pylorus  and  associated  with  pylorospasm  may  be  relieved  and  even  cured  by 
the  operation  of  gastroenterostomy.  In  ulcers  of  other  regions  of  the  stomach 
this  operation  may  also  afford  relief. 

Repeated  haemorrhage,  unless  the  patient  is  too  anaemic  to  withstand  the 
shock  of  operation,  probably  constitutes  an  indication  for  surgical  treatment. 
If  possible  the  bleeding  point  should  be  cauterized  or  excised.  If  these 
are  multiple,  gastroenterostomy  should  be  performed. 

Perforation  should  be  treated  surgically  as  soon  as  the  diagnosis  is  made, 
unless  it  is  an  absolute  certainty  that  adhesions  shutting  off  the  site  of  the 


CANCER   OF    THE    STOMACH.  369 

perforation  from  the  general  peritonaeal  cavity,  have  been  formed.  The  longer 
operation  is  postponed  after  the  contents  of  the  stomach  has  been  emptied 
into  the  peritonaeal  cavity  the  less  the  likelihood  of  the  recovery  of  the  patient. 
Adhesions  about  the  stomach  which  cause  pain  and  other  unpleasant 
symptoms  may  necessitate  surgical  interference.  Hour-glass  contraction 
and  other  post -ulcerous  deformities  of  the  organ  are  also  amenable  to  oper- 
ative treatment. 

CANCER  OF  THE  STOMACH. 

Synonyms.  Gastric  Cancer;  Carcinoma  of  the  Stomach;  Carcinoma 
Ventriculi. 

Etiology.  The  direct  aetiology  of  cancer  is  unknown.  Heredity  plays 
some  part  in  its  causation  and  gastric  ulcer  is  undoubtedly  a  predisposing 
cause.  Cancer  of  the  stomach  is  rarely  seen  before  middle  age  and  is  more 
common  in  males  than  in  females.  It  not  infrequently  occurs  in  individuals 
who  have  had  apparently  healthy  stomachs  during  their  earlier  years. 

Pathology.  Cancer  of  the  stomach  is  usually  primary.  All  varieties  of 
carcinoma  may  occur  in  the  stomach  but  the  most  frequently  seen  are: 

a.  The  scirrhus  which  is  an  infiltrating  growth,  hard  and  dense  in  struc- 
ture; it  usually  involves  a  considerable  portion  of  the  sub  mucosa  and  may 
spread  through  its  whole  extent. 

b.  The  medullary  type  develops  rapidly,  is  likely  to  ulcerate  and  is  prone 
to  extend  directly  or  by  metastasis  to  other  structures. 

c.  The  colloid  variety  grows  to  a  larger  size  than  do  the  other  types  and 
frequently  spreads  by  direct  contiguity  to  neighboring  tissues,  making  with 
them  a  mass  of  considerable  size. 

The  majority  of  gastric  carcinomata  begin  near  the  pylorus  and  from  this 
point  tend  to  extend  along  the  curvatures,  involving  chiefly  the  submucous 
coat.  The  growth,  as  a  rule,  originates  in  the  tubules,  it  progresses,  infiltrating 
and  causing  induration  of  the  remaining  tissues  of  the  organ,  and  results  in 
a  nodular  tumor  which  may  ulcerate.  The  neighboring  lymphatic  glands 
become  hardened  and  enlarged  and  may  themselves  become  the  seat  of  car- 
cinomatous growth.  When  the  tumor  is  at  the  pylorus  stenosis  results  which 
causes  dilatation  of  the  organ,  otherwise  the  stomach  tends  to  diminish  in 
size.  Ulcerations  infrequently  perforate  the  stomach  wall  but  often  erode  a 
blood-vessel  and  cause  hagmorrhage. 

Symptoms.  Before  gastric  cancer  is  suspected  the  patient  is  prone  to  in- 
definite symptoms  referred  to  the  stomach,  such  as  loss  of  appetite,  distress, 
eructations  of  gas  and  constipation,  but  it  must  be  remembered  that  the  growth 
may  exist  for  considerable  time  without  giving  rise  to  any  symptoms  which  call 
attention  to  the  stomach.  The  cancerous  cachexia,  with  its  characteristic 
24 


370         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

color  of  the  skin,  anaemia,  and  loss  of  flesh  and  strength  becomes  sooner  or 
later  apparent  and  palpation  of  the  stomach  may  or  may  not  reveal  the  pres- 
ence of  a  tumor  which  is  rarely  observed  in  the  normal  region  of  the  pylorus. 
It  is  more  likely  to  be  near  the  umbilicus  but  may  be  found  much  lower. 
The  reason  for  this  displacement  is  that  the  weight  of  the  tumor  drags  the 
stomach  downward.  The  tumor  varies  in  size  and  in  consistency  and  may  not 
be  nodular,  it  may  be  either  fixed  or  movable;  a  pyloric  growth  is  not  likely 
to  change  its  position  on  respiration  but  the  contrary  is  true  of  tumors  upon 
the  curvatures.  At  times  when  situated  over  the  aorta  the  tumor  may  seem 
to  pulsate,  but  this  pulsation  is  non-expansile. 

It  is  not  very  unusual  for  no  tumor  to  be  palpable  even  in  the  latest  stages 
of  the  disease. 

As  the  disease  progresses  the  vomiting  usually  becomes  more  distressing. 
The  vomitus  consists  of  food  particles  and  at  times  contains  blood  or  "  coffee- 
ground"  material — the  result  of  the  admixture  of  the  gastric  secretion  and 
blood;  it  may  be  of  foul  odor  and  if  particles  of  food  are  detected  which  have 
been  eaten  a  number  of  hours  previously,  we  may,  in  the  presence  of  other 
suggestive  symptoms,  diagnose  a  malignant  pyloric  stenosis.  Vomiting  is 
Jess  frequent  when  the  growth  is  situated  in  portions  of  the  organ  other  than 
the  pyloric  region.  In  the  later  stages  there  may  be  lymphatic  enlargements 
in  the  clavicular  and  inguinal  regions,  enlargement  of  the  liver,  jaundice, 
oedema  of  the  lower  limbs  and  an  irregular  febrile  movement.  Albumin 
may  be  present  in  the  urine,  and  the  presence  of  metastatic  grov\1:hs,  partic- 
ularly in  the  liver,  may  be  detected.  Blood  examination  shows  a  diminution 
in  the  red  cells,  seldom,  however,  below  2,000,000,  and  a  corresponding 
decrease  in  haemoglobin;  the  haemoglobin  index  is  low,  a  point  which  is  of 
assistance  in  the  differential  diagnosis  from  pernicious  anaemia.  The  white 
blood  cells  are,  as  a  rule,  increased  to  a  moderate  degree — 20,000  or  there- 
abouts— the  increase  being  confined  primarily  to  the  polymorphonuclear 
neutrophiles.  In  advanced  stages  of  the  disease  nucleated  red  cells  and 
myelocytes  have  been  observed. 

The  Stomach  Contents.  Chemical  examination  of  the  gastric  contents 
withdrawn  after  a  test-meal  reveals  an  almost  total  or  an  entire  absence 
of  free  hydrochloric  acid  and  an  excess  of  lactic  acid  (Boas's  sign).  Wliile 
absence  of  free  hydrochloric  acid  and  an  excess  of  lactic  acid  may  occur  in 
other  lesions,  if  repeated  gastric  analyses  after  test-meals  show  these  condi- 
tions to  be  constantly  present  and  the  clinical  symptoms  point  toward  malignant 
neoplasm,  the  probability  is  strongly  in  favor  of  the  existence  of  gastric  cancer. 
The  microscope  should  always  be  employed  in  the  examination  of  the  result 
of  the  test-meal  and  significant  findings  are  blood,  the  Boas-Oppler  bacillus 
and  fragments  of  the  growth.  The  Boas-Oppler  bacillus  is  said  to  be  present 
in  gastric  cancer  almost  without  exception  and  if  a  piece  of  the  tum.or  can 


CANCER    OF    THE    STOMACH.  371 

be  demonstrated  to  be  carcinomatous  tissue  the  diagnosis  is  established 
beyond'  doubt. 

Rontgen  ray  examination  may  reveal  the  presence  of  a  tumor  in  certain 
patients  but  this  means  of  diagnosis  is  as  yet  hardly  trustworthy. 

The  prognosis  is  distinctly  unfavorable,  medical  treatment  offering  no 
hope.  Radical  surgical  intervention,  early  in  the  course  of  the  disease,  may 
be  attended  with  good  results,  but  the  diagnosis  is  seldom  made  before  sur- 
rounding structures  are  involved,  rendering  entire  removal  of  the  malignant 
neoplasm  impossible.  The  disease  is  usually  fatal  within  a  year  but  under 
surgical  treatment  this  period  may  be  slightly  lengthened. 

Treatment.  Medical  treatment  is  merely  palliative  and  consists  in  reliev- 
ing the  pain,  improving  the  digestion  and  keeping  up  the  patient's  nutrition. 
By  attention  to  these  factors  life  may  be  prolonged  and  made  more  comfor- 
table. 

The  pain  may  be  controlled  by  means  of  hot  or  cold  applications  to  the 
epigastrium.  When  it  is  apparently  due  to  retained  and  fermenting  food  it 
may  be  effectually  relieved  by  gastric  lavage  and  removal  of  the  exciting  cause. 
Sodium  chloride,  in  30  grain  (2.0)  doses  well  diluted,  thrice  daily  will  often 
relieve  pain.  The  narcotics  should  be  used  with  care;  belladonna  extract, 
gr.  I  (o.oi),  may  prove  effectual  and  codeine  may  be  employed;  hydrated 
chloral  should  rarely  be  used  because  of  its  liability  to  cause  heart  weakness; 
morphine  may  be  given  hypodermatically  when  all  else  fails. 

The  appetite  may  be  improved  by  the  administration  of  various  stomachics. 
Of  these  condurango  has  been  exploited  as  a  specific  in  gastric  cancer.  While 
exerting  no  effect  upon  the  course  of  the  disease  it  does  increase  the  appetite 
and  aid  digestion.  It  may  be  given  with  hydrochloric  acid  which  also  acts 
as  a  tonic  upon  the  organ,  in  the  following  formula:  I^  fluidextracti  condur- 
ango, §ii  (60.0);  strychninae  sulphatis,  gr.  J  (0.02);  acidi  hydrochlorici  diluti 
5iv  (15.0);  fluidextracti  gentiani  q.s.  ad  §iv  (120.0);  misce  et  signa,  one  tea- 
spoonful  (4.0)  in  a  wine-glass  (60.0)  of  water  through  a  tube,  after  meals. 
Lavage  with  plain  water  or  with  infusions  of  the  vegetable  bitters  cleanses 
the  stomach  and  acts  favorably  upon  the  appetite. 

Vomiting  may  be  controlled  by  lavage  since  it  is  frequently  due  to  the  stag- 
nation and  decomposition  of  food  in  the  stomach.  WTien  the  vomitus  is  of 
foul  odor  washing  the  organ  with  various  antiseptic  solutions  such  as  those 
suggested  under  the  lavage  treatment  of  chronic  gastritis  (p.  352)  is  indi- 
cated. Other  means  of  relieving  nausea  and  vomiting  are  bits  of  cracked  ice 
in  the  mouth,  sips  of  iced  champagne,  carbonic  water,  tincture  of  iodine, 
cold  applications  to  the  epigastrium,  and  hypodermatic  injections  of  mor- 
phine. If  the  vomiting  persists  the  patient  should  be  fed  exclusively  per 
rectum  for  a  few  days. 

(For  the  treatment  of  haematemesis  see  treatment  of  gastric  ulcer, p.  365.) 


372       DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Constipation  is  not  infrequent  and  is  better  treated  dietetically  and  by 
means  of  enemata  of  water  or  oil,  or  suppositories,  than  by  means  of  purgatives. 
In  persistent  instances,  we  may,  however,  employ  the  milder  laxatives,  such 
as  rhamnus  purshiana,  rhubarb  or  aloes,  singly  or  in  combination.  Their 
depleting  effect  should  contra-indicate  the  salines  and  the  purgative  waters. 

Diarrhoea  may  be  combated  by  means  of  phenyl  salicylate  (salol),  bismuth 
subsalicylate  or  subgallate,  beta  naphthol  bismuth  (orphol)  and  other  intes- 
tinal antiseptics.  Stomach  lavage  is  often  effectual  in  preventing  diarrhoea, 
since  it  removes  the  cause,  the  fermented  and  decomposed  contents  of  the 
dilated  stomach. 

The  anaemia  and  cachexia  necessitate  the  administration  of  the  prepara- 
tions of  iron  and  arsenic  and  the  exhibition  of  heart  stimulants,  particularly 
strychnine. 

In  instances  of  carcinoma  with  obstruction  at  the  oesophageal  entrance  the 
passage  of  a  bougie  from  time  to  time  will  keep  the  passage  clear  but  great 
care  must  be  exercised.  Potassium  iodide  and  arsenic  are  said  to  delay 
closure  in  such  patients.  When  swallowing  becomes  impossible  the  patient 
must  be  fed  through  the  tube  or  a  gastric  fistula  must  be  made.. 

Diet  is  the  most  important  factor  in  the  management  of  gastric  cancer  and 
unfortunately  no  suitable  diet  list  can  be  laid  down  as  applicable  to  all.  Each 
patient  must  be  studied  by  himself.  The  food  allowed  should  be  easily  di- 
gestible, finely  divided  and  as  concentrated  as  possible.  The  patient  should 
be  consulted  as  to  what  foods  attract  him  and  what  disagree  with  him  and, 
while  carbohydrates,  fats  and  proteids  may  be  allowed  when  there  is  no  ob- 
struction or  fermentation,  when  these  are  present  the  diet  should  be  chiefly 
of  proteid.  It  is  usually  best  to  prescribe  small  meals  at  frequent  intervals 
especially  if  there  is  motor  insufficiency.  Milk  in  small  amount  at  a  time  may 
be  given  if  it  is  well  borne;  peptonized  milk,  the  fermented  milks,  koumyss, 
matzoon  and  kefir,  often  are  preferred  by  the  patient;  all  meats  and  fish 
should  be  eaten  minced  and  in  small  amounts  only,  at  a  time.  The  green 
vegetables,  cereals,  puree  soups,  stewed  fruits,  toast  and  zwieback  are  allow- 
able as  are  also  cocoa,  chocolate,  especially  von  Mehring's"  Kraft-chocolade," 
tea  and  cofl'ee.  Alcoholic  drinks,  such  as  beer,  which  are  likely  to  ferment  in 
the  stomach  should  not  be  taken  but  the  light  wines  may  be  permitted.  The 
artificial  substitutes  for  meat  may  be  given  but  they  are  merely  makeshifts; 
of  these  the  best  are  probably  nutrose  and  somatose. 

Surgical  treatment  affords  the  only  hope  of  complete  recovery  from  gastric 
cancer  and  this  may  be  brought  about  only  when  operative  interference  is  un- 
dertaken in  the  early  stages.  The  operation  consists  in  complete  removal 
of  the  tumor  and  is  most  likely  to  prove  successful  when  this  is  situated  at 
the  pylorus. 

When  the  disease  has  progressed  so  far  that  removal  of  the  neoplasm  in 


HYPERTROPHIC    STENOSIS    OF    THE    PYLORUS.  373 

its  entirety  is  impossible,  a  gastroenterostomy  permits  free  egress  of  the  stom- 
ach contents  into  the  intestine  and  prolongs  the  patient's  life.  He  may 
even  gain  flesh  for  a  time  following  this  procedure. 

Certain  authors  believe  that  in  all  patients,  in  which  the  diagnosis  of 
gastric  cancer  cannot  be  ruled  out,  an  exploratory  laparotomy  is  indicated 
and  that  even  benign  pyloric  strictures  should  be  excised. 

HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS. 

Definition.  A  condition  characterized  by  hypertrophy  of  the  muscular 
coat  of  the  stomach  at  the  pyloric  orifice  and  usually  accompanied  by  spasm 
and  interference  with  the  passage  of  stomach  contents  into  the  duodenum. 

.Etiology.  The  aetiology  of  the  congenital  form  is  unknown;  the  acquired 
variety  is  rarely  seen  before  middle  age  and  ovir  knowledge  of  the  causation 
of  it  is  limited.  It  may  occur  as  a  result  of  a  congenital  abnormality  but  more 
frequently  appears  to  be  due  to  a  chronic  inflammatory  condition  of  the 
stomach.     The  disease  is  a  rare  one. 

Pathology.  In  the  congenital  type  the  muscularis  of  the  entire  stomach 
is  the  seat  of  some  degree  of  hyperplasia,  but  especially  is  this  the  case  at  the 
pylorus;  here  the  gastric  wall  is  firm  to  the  feel  and  dense  in  texture.  The 
chief  seat  of  the  hypertrophy  is  the  coat  of  circular  fibres,  the  longitudinal 
coat  seldom  being  much  involved.  The  stomach  itself  may  be  contracted 
and  the  pyloric  hypertrophy  may  extend  to  some  extent  throughout  the  remain- 
der of  the  muscularis.     Dilatation  of  the  organ  is  unusual. 

In  the  acquired  variety  of  this  condition,  when  the  hypertrophied  tissue  is 
limited  in  extent  to  the  pyloric  region,  there  is  likely  to  be  dilatation,  when 
there  is  general  thickening  of  the  muscular  coat  contraction  of  the  organ  is 
more  common. 

Symptoms.  Congenital  pyloric  stenosis  is  evidenced  by  frequent  and  per- 
sistent vomiting  without  assignable  cause.  The  vomiting  may  occur  directly 
after  the  ingestion  of  food  or  an  hour  or  more  later  and  the  fact  that  no  bile  is 
found  in  the  vomitus  is  significant.  Rarely  is  a  tumor  palpable.  The  patient 
rapidly  becomes  emaciated  and  death  may  follow  within  3  or  4  months. 

In  advilts  the  principal  symptom  is  gastric  pain  with  a  sense  of  fullness  and 
pressure.  If  there  is  co-existent  dilatation  and  muscular  atony,  emesis  may 
occur.  A  palpable  tumor  may  or  may  not  be  present  but  the  thickened  pylorus 
is  usually  distinguishable  by  the  skilled  observer,  especially  in  thin  subjects 
and  fortunately,  for  the  sake  of  diagnosis,  these  patients  usually  are  ill-nour- 
ished although  true  cachexia  is  not  a  feature  of  the  condition.  This  fact, 
together  with  the  rarity  of  the  disease  and  its  freedom  from  haematemesis,  is 
a  useful  point  in  the  differentiation  from  malignant  disease.  The  prognosis 
as  to  recovery  without  operation  is,  in  both  types  of  this  disease,  bad. 

Treatment.     The  palliative  treatment  of  the  congenital  form  consists  of 


374         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

lavage  to  remove  retained  food  and  to  prevent  vomiting.  Feeding  through 
the  tube  may  relieve  that  form  of  reflex  vomiting  v^^hich  sometimes  results 
from  the  mere  act  of  deglutition.  Surgical  intervention  in  pyloric  stenosis 
offers  the  only  hope  of  recovery.  The  operations  applicable  are  gastroenter- 
ostomy, pyloroplasty  and  excision  of  the  pylorus.  Loreta's  operation 
(manual  dilatation  of  the  pyloric  orifice)   is  not  advised. 

In  adults  the  treatment  aside  from  surgical  interference  is  that  of  the 
causative  chronic  gastritis  (see  p.  351  and  ff.). 

GASTRIC  DILATATION. 

Synonyms.     Dilatation  of  the  Stomach;  Gastrectasis. 

Definition.     A  condition  of  the  stomach  in  which  its  capacity  is  increased. 

.Etiology.  In  the  causation  of  gastric  dilatation  two  factors  must  be  taken 
into  account,  i.  Atony  of  the  musculature  of  the  organ  due  to  frequent  dis- 
tention by  excessive  quantities  of  food  or  drink,  to  inflammatory  interference 
with  the  nourishment  of  the'  stomach,  as  in  chronic  gastritis,  and  to  various 
constitutional  diseases  which  lower  the  tone  of  the  muscular  system  in  general, 
such  as  the  acute  infectious  diseases,  pulmonary  tuberculosis,  various  nervous 
diseases,  the  anaemias,  diseases  of  the  heart,  liver  or  kidneys,  etc.  2.  Dilatation 
due  to  pyloric  obstruction  caused  by  malignant  grovrths,  hypertrophy  or  thick- 
ening of  the  gastric  wall  at  this  situation,  contraction  of  cicatrices  following 
ulcers,  traumatism,  etc.,  and  pressure  from  without  of  adhesions,  abdominal 
tumors  or  misplaced  viscera,  or  the  habitual  wearing  of  over-tight  corsets. 
The  disease  is  one  of  adult  life,  though  it  has  been  met  in  children. 

Pathology.  The  capacity  of  the  organ  may  be  increased  to  three  or  four 
times  the  normal,  which  is  a  little  over  a  quart  (litre).  Its  lower  border  is, 
in  consequence,  markedly  displaced  downward.  There  is  atrophy  of  all  the 
coats  and  the  wall  is  often  thinned  as  a  result  of  the  stretching  which  it  has 
undergone,  while  at  times  there  may  be  thickening  due  to  the  replacement  of 
the  normal  structure  with  connective  tissue. 

Symptoms.  These  are  a  sense  of  weight  in  the  epigastrium,  especially 
after  a  full  meal,  eructations  of  gas  often  mixed  with  liquid  or  food  particles, 
and  nausea,  which  at  times  is  followed  by  emesis.  The  vomitus  is  frequently  of 
large  amount  and  may  be  seen  to  contain  bits  of  food  which  have  been  ingested 
a  number  of  days  previously.  The  appetite  may  be  good  or  poor  and  there 
is  often  thirst.  The  bowels  are  usually  constipated  and  the  urine  is  often 
scanty,  highly  colored  and  loaded  with  urates. 

As  the  disease  progresses  the  patient  becomes  anaemic,  weak  and  emaciated. 
A  condition  known  as  gastric  tetany  may  develop  as  a  result  of  absorption  of 
the  toxins  generated  by  the  decomposition  of  the  stagnant  food  retained  in 
the  stomach.  The  tetanic  convulsions  follow  premonitory  sensations  of 
drowsiness,  tingling  of  the  extremities  and  sometimes  vomiting.     The  move- 


GASTRIC    DILATATION.  375 

ments  affect  both  sides  of  the  body,  one,  usually,  less  than  the  other,  involve 
chiefly  the  muscles  of  the  limbs  and  face  and  are  accompanied  by  pain.  Death 
from  exhaustion  and  preceded  by  loss  of  consciousness  is  a  frequent  conse- 
quence (75  percent,  of  patients). 

Physical  Signs.  Inspection  in  thin  patients,  particularly  if  the  stomach 
is  distended  with  food  or  gas,  may  reveal  the  greater  curvature  even  several 
inches  below  its  normal  level  (i^  to  2  inches  above  the  umbilicus)  and  in 
marked  instances  the  line  of  the  lesser  cm-vature  may  be  demonstrable.  Peris- 
taltic movements  from  right  to  left  may  be  observed  to  stop  at  the  pyloric 
region  where  a  prominence  due  to  a  tumor  may  be  visible.  If  the  organ  is 
artificially  distended  by  gas,  resulting  from  the  administration  of  \  drachm 
(2.0)  of  tartaric  acid  in  a  little  water  and  a  couple  of  drachms  (8.0)  of  sodium 
bicarbonate,  also  in  water,  given  separately,  or  by  inflating  with  a  bicycle  pump 
through  an  ordinary  stomach  tube,  the  examination  will  be  greatly  facilitated. 
One  must  be  careful  however  to  rule  out  the  possibility  of  ulcer  before  employ- 
ing these  procedures. 

Palpation  enables  us  to  feel  what  we  have  hitherto  seen  and  even  when  not 
visible,  the  border  of  the  stomach  may  be  demonstrated  by  this  means.  A  pal- 
pable tumor  may  be  made  out  and  peristalsis  also  may  be  felt.  Light  pressure 
quickly  made  and  as  quickly  released  may  bring  out  splashing  sounds  which 
may  be  distinctly  audible  to  the  lower  limit  of  the  organ.  These  sounds  are 
more  easily  obtained  and  more  plainly  heard  than  over  the  normal  stomach. 

Percussion  plainly  evidences  the  borders  of  the  enlarged  organ,  the  note 
over  it  being  tympanitic  in  character  when  the  patient  is  recumbent;  when 
he  is  upright  it  is  flat  in  its  lower  part  owing  to  the  fluid  or  food  in  its  most 
dependent  portion;  distention  of  the  stomach  by  water  and  of  the  colon  by 
air  or  vice  versa  may  aid  the  observer  in  mapping  out  the  borders  of  the  organ. 

The  use  of  the  stiff  sound  may  show  the  greater  ciurvature  to  be  at  a  lower 
level  than  normal,  and  its  extremity  may  be  palpable  through  a  thin  abdom- 
inal wall. 

The  gastrodiaphane,  an  instrument  constructed  to  illuminate  the  stomach 
by  electric  light,  may  be  employed.  This,  in  a  word,  consists  of  a  small 
incandescent  lamp  at  the  extremity  of  a  stomach  tube  and  when  passed  into 
the  organ  aids  in  determining  its  size  and  position.  The  examination  must 
take  place  in  a  dark  room.  When  the  stomach  is  filled  with  a  fluorescent 
medium  the  value  of  this  method  of  examination  is  much  enhanced.  Also 
bismuth  subnitrate  in  dose  of  2  drachms  (8.0)  may  be  administered  and 
the  patient  subjected  to  a  fluoroscopic  examination  ten  minutes  later.  Skia- 
graphs, likewise,  taken  after  the  ingestion  of  bismuth  may  demonstrate  the 
gastric  enlargement. 

The  administration  of  certain  drugs  which  are  not  absorbed  from  the  stom- 
ach and,  which  after  passing  the  pylorus,  are  excreted  in  the  urine  is  another 


376         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

means  of  testing  the  gastric  tonicity  and  the  patency  of  the  pylorus.  In  this 
connection  phenyl  salicylate  (salol)  may  be  employed.  Normally  salicy- 
luric acid  should  be  present  in  the  urine  within  5  or  6  hours  after  its  admin- 
istration. Urine  containing  this  acid  takes  a  port  wine  color  upon' the  addi- 
tion of  a  small  quantity  of  the  tincture  of  iron  chloride. 

Stomach  Contents.  The  organ  should  be  washed  on  the  evening  before  the 
test-meal  is  given  in  order  to  remove  its  decomposing  and  stagnant  contents. 
The  examination  of  a  test-meal  withdrawn  an  hour  after  its  ingestion  gives 
evidence  of  delayed  and  imperfect  digestion  and  if  cancer  is  present  there 
will  usually  be  absence  of  free  hydrochloric  acid  and  presence  of  lactic  acid 
and  the  Boas-Oppler  bacillus,  otherwise  the  content  of  free  hydrochloric  acid 
is  variable.  Numerous  organisms,  yeasts,  sarcinas  and  other  bacteria,  are 
usually  present  in  large  numbers  and  butyric  and  acetic  acids  may  be  found. 

Treatment.  The  medicinal  treatment  of  this  condition  consists  in  admin- 
istering drugs  calculated  to  improve  the  muscular  tone  of  the  stomach  and 
to  lessen  the  tendency  to  decomposition  of  the  retained  food.  As  a  muscle 
tonic  strychnine  is  most  valuable.  It  may  be  given  alone  or  in  combination 
with  physostigma — strychnine  sulphate,  gr.  21J  (0-003)  ^^^  extract  of  physos- 
tigma,  gr.  \  (o.oi)  three  times  a  day.  If  the  hydrochloric  acid  is  diminished 
in  quantity  the  dilute  acid  should  be  prescribed;  this  substance  is  also  useful 
in  neutralizing  the  gastric  fermentation.  Hyperacidity  may  be  neutralized 
by  heavy  magnesia,  gr  x  (0.66),  bismuth  subcarbonate  and  sodium  bicarbonate, 
of  each,  gr.  v  (0.33)  given  about  an  hour  after  meals,  and  fermentation  may  be 
retarded  by  the  following  formulae  I^  resorcinolis,  gr.  Ixxv  (5.0) ;  bismuthi  sub- 
salicylatis,  pulveris  rhei,  sodii  sulphatis  aa  oii  ss  (10. o);  sacchari  lactis  5iii  ss 
(14.0);  misce  et  signa,  \  teaspoonful  (2.0)  twice  a  day  (Ewald).  Pancreatin 
may  be  used  in  patients  which  do  not  bear  hydrochloric  acid  well,  and  creosote 
and  guaiacol  are  recommended — ^\  v  (0.33)  in  capsules — as  antifermentatives. 

Lavage  usually  will  relieve  the  vomiting  and  at  the  same  time  is  an  impor- 
tant adjunct  to  the  treatment,  since  by  this  means  we  may  remove  the  decom- 
posing contents  of  the  stomach.  The  addition  to  the  wash  water  of  antisep- 
tics (see  p.  352)  is  often  advisable. 

Constipation  is  frequent,  the  intestine  being  often  atonic  as  well  as  the 
stomach.  Purgatives  should  never  be  given  but  a  movement  of  the  bowels 
should  be  secured  daily  by  diet  regulation.  A  glass  or  two  of  cold  water 
on  rising  and  the  ingestion  of  stewed  fruits,  green  vegetables,  graham  or  whole 
wheat  bread,  together  with  proper  abdominal  massage  and  electricity,  usually 
suffice  in  this  regard.  Intestinal  irrigations  may  be  given  from  time  to  time.  If 
laxatives  are  absolutely  necessary  rhamnus  purshiana  is  the  least  objectionable. 

Massage  and  electricity  are  necessary,  the  former  being  employed  only 
when  the  stagnant  contents  of  the  stomach  has  been  removed  and  the  latter, 
the  intra-gastric  faradic  current  especially,  is  to  be  given  as  described  on  p.  354. 


ACUTE    GASTRIC    DILATATION.  377 

The  tonic  effect  of  hydrotherapeutic  procedures,  especially  the  cold  morning 
sponge,  is  not  to  be  overlooked  and  the  fact  that  properly  fitting  abdominal 
binders  can  do  much  toward  supporting  the  prolapsed  and  enlarged  organ 
must  not  be  ignored. 

Diet.  The  patient  must  be  warned  not  to  eat  or  drink  large  quantities 
at  a  time,  but  should  be  advised  that  four  to  five  small  meals  per  day  are  prefer- 
able to  three  large  ones  and  that  he  must  avoid  all  foods  likely  to  cause  fer- 
mentation— especially  fats  and  sweets.  Liquids  should  be  restricted  to  a 
quantity  not  greater  than  3  pints  (i^  litres)  during  the  24  hours.  If  thirst  is 
troublesome  further  fluids  may  be  given  per  rectum. 

The  conditions  revealed  by  repeated  gastric  analysis  will  demonstrate 
the  diet  appHcable  to  each  particular  case.  With  plenty  of  free  hydrochloric 
acid  the  red  meats  may  be  allowed,  also  cereals,  gruels,  eggs,  and  vegetables 
which  last  must  be  mashed  or  better  given  in  puree  form;  the  carbohydrates 
aside  from  those  above  mentioned  must  be  restricted.  When  the  free  hydro- 
chloric acid  is  abnormally  small  in  amount  more  carbohydrates  may  be  taken 
but  the  animal  proteid  element  of  the  diet  should  be  restricted  to  the  white 
meats,  fish,  calves'  thymus,  etc. 

Alcoholic  drinks  are  best  omitted,  but  when  a  light  sweet  or  sour  wine 
seems  to  benefit  the  patient  it  may  be  allowed  in  small  quantity — two  sherry 
glasses  at  each  meal,  for  instance. 

Surgical  Treatment.  For  patients  who  continue  unrelieved  despite  medical 
treatment  the  question  of  surgical  intervention  must  be  considered.  Where 
the  dilatation  and  atony  are  due  to  pyloric  obstruction  pyloroplasty,  pylorec- 
tomy  or  gastroenterostomy  is  applicable,  depending  upon  the  conditions  which 
confront  us. 

A  dilatation  depending  merely  upon  atony  of  the  gastric  musculature  may 
be  relieved  by  a  gastroenterostomy  or  by  gastroplication.  Both  physician 
and  patient,  however,  must  not  lose  sight  of  the  fact  that  none  of  these  oper- 
ative procedures  is  by  any  means  certain  to  bring  about  complete  relief  and 
that  the  adhesions  and  other  factors  that  are  likely  to  follow  a  laparotomy 
may  render  the  patient's  discomfort  little  less  than  before  he  entered  the 
siu-geon's  hands. 

ACUTE  GASTRIC  DILATATION. 

Synonym.     Acute  Gastrectasis. 

Definition.     An  acute,  rapid  dilatation  of  the  stomach. 

.Etiology.  Various  causes  are  said  to  bring  about  this  rare  condition; 
certain  instances  appear  to  be  idiopathic,  others  take  place  as  a  result  of  some 
influence  on  the  nervous  system  producing  a  paralysis  of  the  nerves  of  the 
organ  in  question.  Acute  dilatation  may  occur  during  the  infectious  diseases, 
pneumonia,  meningitis  or  peritonitis;  as  a  result  of  acute  obstruction  of  the 


378         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

pylorus,  as  from  a  foreign  body;  after  parturition,  abdominal  operations,  or 
anaesthesia,  where  it  has  been  thought  to  be  due  to  the  swallowing  of  anaes- 
thetic-impregnated mucus  from  the  throat.  Constriction  of  the  duodenum  by 
the  superior  mesenteric  vessels  has  been  considered  a  factor  in  its  causation, 
and  it  may  follow  the  rapid  consumption  of  very  large  amounts  of  food  and 
drink. 

Pathology.  After  death  the  wall  of  the  stomach  is  thin,  its  cavity  is  large 
and  its  greater  curvature  may  extend  far  below  the  umbilicus.  The  viscus 
contains  gas,  fluid  which  is  usually  watery  and  of  a  greenish  tinge,  rarely  it  is 
thick  and  brownish,  and  perhaps  undigested  food. 

There  may  be  drops  of  blood  upon  the  lining  of  the  organ  and  the  blood- 
vessels are  dilated. 

Symptoms.  The  onset  of  the  condition  is  usually  sudden,  although  after 
operations  it  may  not  appear  for  a  day  or  two.  There  is  usually  little  pain 
and  the  thirst  is  marked.  The  abdomen  is  greatly  distended  and  vomiting 
is  present  as  a  rule,  the  vomitus  being  thin  and  tinged  with  green  or  brown. 
The  outline  of  the  stomach  is  often  plainly  apparent  but  peristalsis  is  seldom 
visible.  There  is  no  rigidity  of  the  abdominal  wall.  The  constitutional 
symptoms  are  those  of  great  depression,  with  subnormal  temperature,  rapid, 
weak  pulse  and  rapid  and  shallow  respiration.  Death  may  take  place  in 
collapse.     The  prognosis  is  bad  but  all  instances  do  not  terminate  fatally. 

Treatment.  Prophylaxis  consists  in  washing  the  stomach  if  there  is  marked 
vomiting  after  anaesthesia.  Since  the  condition  may  be  the  result  of  the 
absorption  of  toxic  substances  from  the  stomach  this  organ  should  be  subjected 
to  frequent  lavage,  and  the  intestine  should  be  cleared  by  means  of  high 
irrigations.  Rest  from  the  work  of  digestion  is  advisable,  consequently  rectal 
alimentation  should  be  undertaken,  and  as  relapses  may  occur  even  after 
several  days,  food  and  drink  by  mouth  should  be  given  with  the  utmost 
caution.  As  soon  as  the  condition  of  the  stomach  will  allow,  small  doses  of 
calomel  or  of  a  saline  should  be  given  and  frequently  repeated. 

The  constitutional  depression  should  be  combated  by  means  of  hypoder- 
matic stimulation — especially  strychnine  and  atropine — hot  applications  to 
the  extremities,  hj'podermatoclysis,  etc. 

HOUR-GLASS  OR  BILOCULAR  STOMACH. 

Definition.  A  condition  in  which  the  stomach  is  divided  by  a  constriction 
into  two  parts,  more  or  less  equal  in  size.  It  is  a  rare  state  and  still  more 
rarely  is  the  organ  separated  into  three  or  more  sacs. 

.Etiology.  The  bilocular  stomach  may  be  congenital — though  this  state- 
ment is  refuted  by  some  authorities — or  acquired.  The  latter  form  is  usually 
the  result  of  the  cicatricial  contraction  of  vilcers  or  erosions  from  the  ingestion 


VISCEROPTOSIS.  379 

of  corrosive  substances,  more  seldom  is  it  due  to  outside  adhesions  or  malignant 
growths.  The  theory  has  been  advanced  that  it  may  follow  tight  lacing. 
There  is  said  to  be  at  times  a  contraction  of  the  gastric  musculature  at  the 
seat  of  the  constriction. 

Pathology.  The  organ  presents  a  sacculated  appearance  and  at  the  con- 
striction the  muscle  fibres  may  be  thickened.  This  is  by  no  means  always 
the  case  for  the  narrowest  part  of  the  organ  may  be  devoid  of  muscular  tissue 
and  consist  of  a  fibrous  cicatrix. 

Symptoms.  Moderate  degrees  of  hour-glass  stomach  often  cause  no  char- 
acteristic symptoms.  There  is  usually  more  or  less  discomfort  referred  to  the 
organ,  which  at  times  may  be  increased,  due  to  spasm  of  the  hypertrophied 
muscle  fibres  about  the  constriction.  The  fact  that  the  gastric  muscle  must 
force  the  ingesta  over  and  through  the  contraction  finally  gives  rise  to  an 
atonic  condition  which  is  likely  to  result  in  dilatation.  Diagnosis  without 
physical  examination  is  impossible  and  fortunately  the  condition  is  accompan- 
ied by  a  number  of  unmistakable  signs.  When  the  stomach  seems  empty 
and  the  tube  has  been  passed  with  no  result  palpation  may  elicit  a  splashing 
sound,  due  to  the  fact  that  the  pyloric  sac  of  the  organ  contains  fluid  while 
the  cardiac  sac  is  truly  jejune.  At  times  during  lavage  the  reflux  will  be  found 
to  exceed  the  influx  in  quantity.  Distention  of  the  organ  by  air  may,  in  thin 
subjects,  reveal  the  constriction  with  a  dilatation  upon  either  side.  When 
this  sign  cannot  be  seen  the  borders  of  the  stomach  may  be  palpable  and 
the  condition  thus  made  out.  The  two  portions  of  a  Seidlitz  powder  given 
separately  by  their  evolution  of  gas  will  distend  the  cardiac  sac  at  once  while 
the  pyloric  sac  may  not  be  distended  at  all  or  may  be  seen  to  slowly  enlarge 
as  the  gas  enters  it  through  the  constriction.  The  gastrodiaphane  may 
simplify  the  diagnosis  and  Hemmeter's  rubber  bag  when  inflated  in  the 
stomach  reveals  a  distention  of  the  cardiac  pouch  only.  A  skilled  manipula- 
tor may  succeed  in  passing  a  tube  through  the  constriction  and  obtaining 
contents  from  the  pyloric  pouch  which  differs  materially  on  chemical  analysis 
from  that  previously  obtained  from  the  cardiac  sac. 

Long  standing  instances  of  this  condition  lose  flesh  and  strength,  lack 
proper  nutrition  and  may  terminate  fatally. 

Treatment,  aside  from  relieving  the  symptoms,  is  purely  surgical  and  con- 
sists in  the  performance  of  a  plastic  operation  at  the  site  of  the  constriction 
or  of  a  gastroenterostomy  to  bring  about  a  communication  between  both  sacs 
and  the  intestine. 

VISCEROPTOSIS. 

Synonyms.  Glenard's  Disease;  Splanchnoptosis;  Enteroptosis;  Gastrop- 
tosis. 

Definition.     A  condition  characterized  by  a  falling  of  the  abdominal  viscera 


380        DISEASES    OF    THE    DIGESTIVE    SYSTEM   AND    PERITONEUM. 

to  a  level  lower  than  the  normal  and  due  to  a  relaxed  state  or  stretching  of 
the  mesenteries  and  peritonaeal  ligaments  combined  with  relaxation  of  the 
muscular  wall  of  the  abdomen.  The  ptosis  may  involve  the  liver,  spleen, 
stomach,  intestines  and  kidneys. 

.Etiology.  This  condition  is  more  common  in  women  in  the  proportion 
of  about  3  to  I,  this  fact  probably  being  due  less  to  the  wearing  of  over-tight 
corsets  than  to  the  extraordinary  stretching  of  the  abdominal  wall  attendant 
upon  pregnancy.  The  loss  of  muscular  tone  and  of  fat  resulting  from 
prolonged  inflammations  of  the  alimentary  tract,  from  the  wasting  diseases, 
excessive  loss  of  blood,  etc.,  and  over-exertion  predispose  to  downward  dis- 
placements of  the  abdominal  viscera.  Glenard's  original  hypothesis  that  a 
dislocation  of  the  hepatic  flexure  of  the  colon  caused  by  a  stagnation  of  faecal 
matter  is  the  beginning  of  a  general  ptosis  is  probably  less  correct  than  the 
theory  that  the  condition  is  due  to  factors  such  as  those  mentioned  above. 
Of  late  the  idea  has  been  advanced  that  there  may  be  a  congenital  predis- 
position to  visceroptosis  since  in  the  foetus  and  even  in  the  newly-born  child 
the  viscera  may  occupy  an  analogous  position  in  the  abdominal  cavity. 

The  fact  that  the  displacement  may  not  involve  all  the  abdominal  organs 
must  not  be  overlooked,  for  it  is  not  unusual  to  find  a  kidney,  the  stomach, 
the  liver  or  the  spleen  in  abnormal  locations. 

Symptoms.  These  are  indefinite  and  indeed  the  condition  may  exist 
without  causing  any  symptoms  whatever.  In  general,  however,  the  patient 
complains  of  various  dyspeptic  symptoms,  such  as  poor  appetite,  sensations 
of  distention  and  weight  and  eructations  and  rumblings  in  the  digestive  tract. 
Rarely  the  appetite  may  be  increased;  the  bowels  are  usually  constipated, 
though  the  opposite  condition  may  be  present.  The  breath  may  be  foul, 
the  tongue  coated  and  the  mouth  dry.  Nervous  manifestations,  such  as 
dizziness,  depression  of  spirits,  headache,  sleeplessness,  palpitation,  and  tin- 
gling and  sensations  of  cold  in  hands  and  feet  are  frequent.  Considerable 
bodily  emaciation  is  not  rare.     A  chlorotic  condition  of  the  blood  is  frequent. 

Physical  examination  reveals  an  abdomen  prominent  and  baggy  in  its 
lower  part,  relaxed  and  thin  of  wall.  On  palpation  the  abdomen  has  a 
characteristic  doughy  feeling  and  splashing  sounds  may  be  easily  elicited. 
The  edge  of  the  liver,  when  this  organ  is  displaced,  may  be  felt  lower  than 
normal,  the  kidneys  and  spleen  may  be  palpated.  Percussion  of  the  liver 
shows  its  upper  limit  to  be  displaced  downward.  The  displacement  of  the 
stomach  may  be  demonstrated  by  any  of  the  means  described  under  gastric 
dilatation  (p.  375  and  ff.)  and  it  may  be  shown  to  be  in  a  position  more  vertical 
than  normal,  its  cardiac  end  usually  being  in  the  normal  situation  and  the 
pylorus  far  from  its  proper  site.  The  tenth  rib  may  be  movable  (Stiller's 
sign). 

Treatment.     Drugs  have  no  great  part  in  the  management  of  this  condition 


VISCEROPTOSIS.  381 

the  principal  object  being  to  replace  the  abnormally  situated  viscera  and  to 
maintain  them  in  their  normal  position.  This  may  best  be  done  by  putting 
the  patient  in  bed,  keeping  him  there  and  fattening  him.  He  should  be  over- 
fed and  as  adjuvants  to  this  treatment  faradic  electricity  and  the  high  fre- 
quency current  may  be  employed.  Physostigmine  salicylate  in  doses  of  gr. 
j^-^  (0.0006)  three  times  a  day  is  useful  to  restore  the  tonus  of  the  intestinal 
musculature.  This  may  be  given  alone  or  in  combination  with  strychnine 
sulphate  gr.  -j^  to  -jq-  (0.003-0.0025)  and  capsicum,  gr.  i  (0.065). 

The  bowels  should  be  kept  open  by  means  of  vegetable  laxatives  such  as 
aloes  or  rhamnus  purshiana  if  necessary,  but  the  diet  should  be  depended 
upon  to  regulate  this  function  in  so  far  as  possible,  fruits  and  foods  leaving 
an  undigested  residue  being  particularly  indicated.  When  diarrhoea  is  present 
it  may  be  controlled  by  intestinal  antiseptics  such  as  bismuth  subsalicylate, 
resorcinol  or  benzo-naphthol,  and  when  gastric  analysis  shows  hydrochloric 
acid  to  be  diminished  in  quantity  this  substance  may  be  supplied. 

When  the  cure  by  means  of  rest  in  bed  is  inconvenient  or  impossible  tlie 
patient  may  receive  much  relief  from  wearing  a  properly  fitting  abdominal 
binder  such  as  can  be  fiirnished  by  any  reliable  truss  maker.  The  patient 
should  be  taught  by  his  physician  how  to  replace  the  viscera  and  this  should 
be  done  in  bed  each  morning  and  the  belt  applied  before  the  erect  position 
is  assumed. 

As  a  substitute  for  the  abdominal  band  strapping  with  zinc  oxide  adhesive 
plaster  (preferably  spread  on  moleskin)  strips  has  been  suggested  and  often 
achieves  excellent  results  (Rose). 

It  should  hardly  be  necessary  to  state  that  tight  lacing  is  contra-indicated 
in  ptosis  of  the  viscera  and  that  women  should  be  advised  to  wear  skirts 
suspended  from  the  shoulders  rather  than  from  the  hips. 

Physical  methods  such  as  massage,  either  by  the  physician  or  the  patient 
himself,  moderate  exercise,  such  as  bicycling,  golf,  etc.,  and  hydriatic  pro- 
cedures have  a  place  in  the  management  of  this  condition  after  the  rest  cure 
has  succeeded  in  restoring  the  organs  to  their  normal  situations. 

The  dietetic  treatment  of  visceroptosis  offers  difficulties.  The  problem 
in  hand  is  to  fatten  an  individual  whose  powers  of  digestion  and  assimilation 
are  impaired  and  to  over-feed  such  a  patient  without  disturbing  his  already 
poor  digestive  ability  is  not  an  easy  task.  And  again  the  difficulty  is  enhanced 
by  the  fact  that  the  regimen  for  each  patient  must  be  chosen  with  reference  to 
his  particular  capabilities.  During  the  early  part  of  the  rest  cure  a  milk 
diet  should  be  instituted  if  the  patient  can  digest  and  is  satisfied  with  it,  later 
more  latitude  may  be  allowed  and,  if  the  digestive  powers  permit,  a  general 
diet  should  be  prescribed. 

If  the  patient  is  not  undergoing  the  rest  cure  and  is  up  and  about  he  shovild 
not  eat  large  quantities  at  a  time  lest  the  stomach  become  over-loaded  and  the 


382         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

ptosis  accentuated;  here  four  or  five  small  meals  per  day  of  concentrated 
food  stuffs  are  preferable  to  three  of  large  or  ordinary  size.  Fats  may  be  eaten 
if  they  can  be  digested.  Gastric  analysis  and  observation  of  the  patient  in 
hand  will  indicate  far  better  the  proper  diet  than  can  any  list  of  food  articles 
arbitrarily  set  down. 

Surgical  measures,  such  as  taking  reefs  in  the  lengthened  mesenteries, 
suturing  the  lesser  curvature  of  the  stomach  or  its  anterior  wall  to  the  anterior 
parietes  of  the  abdomen  and  suturing  the  edges  of  the  recti  abdominis 
muscles  together  after  having  removed  the  intervening  tissues,  have  been 
employed  with  varying  results. 

NEUROSES  OF  THE  STOMACH. 
HYPERCHLORHYDRIA. 

Synonyms.  Gastric  Hyperacidity;  Gastrosuccorrhoea;  Gastroxynsis;  Nerv- 
ous Hypersecretion  of  Hydrochloric  Acid. 

Definition.  E.xcessive  secretion  of  hydrochloric  acid  by  the  gastric  tubules 
occurs  in  various  gastric  disorders  but  there  is  a  class  of  patients  in  which 
there  is  a  hypersecretion  of  gastric  juice  which  takes  place  in  the  absence  of 
food  or  of  any  inflammatory  condition.  It  is  usually  considered  a  neurosis 
and  exists  in  two  chief  forms. 

a.  Paroxysmal  hyperchlorhydria. 

b.  Continuous  hyperchlorhydria.  This  is  a  chronic  state  and  was  first 
described  by  Reichmann  whose  name  has  since  that  time  been  associated 
with  the  condition. 

.Etiology.  Hyperchlorhydria  has  no  distinct  causative  factor.  It  is 
most  frequently  observed  in  persons  of  neurotic  temperament.  It  is  more 
common  in  the  young  and  middle-aged  and  is  often  seen  in  chlorotic  subjects; 
it  is  predisposed  to  by  various  mental  influences  such  as  grief,  worry,  etc. 
Some  subjects  are  afflicted  with  it  directly  after  eating  or  drinking  certain 
substances. 

Symptoms.  These  are  practically  identical  in  the  two  forms  except  that 
in  the  paroxysmal  variety  they  appear  intermittently  while  in  the  continuous 
type  they  are  always  present.  The  most  prominent  symptoms  are  pain  refer- 
red to  the  stomach,  "heart  burn,"  the  eructation  of  gas,  thirst  and  nausea. 
Vomiting  is  infrequent  and  when  present  the  very  acid  taste  of  the  vomitus 
is  noticed.  Headache  is  common.  The  appetite  is  usually  good  and  the 
bowels  are,  as  a  rule,  constipated.  The  acidity  of  the  urine  may  be  reduced 
owing  to  the  excess  of  gastric  acidity. 

In  the  paroxysmal  form  of  the  disease  the  symptoms  may  last  only  a  few 
hours  or  may  be  prolonged  for  a  number  of  days  to  be  terminated  by  treat- 


HYPERCHLORHYDRIA.  383 

ment  or  in  an  attack  of  vomiting.  In  the  continuous  type  the  pain  is  more 
marked  and,  if  untreated,  the  patient  may  lose  flesh  and  strength.  In  long 
standing  instances  anemia  is  not  rare. 

The  prognosis  as  regards  improvement  is  very  favorable  and  cures  are 
not  infrequent. 

The  diagnosis  can  be  made  certainly  only  by  means  of  chemical  analysis 
of  the  gastric  contents.  A  test-meal  removed  two  or  three  hours  after  ingestion 
will  consist  of  a  small  amount  of  thoroughly  digested  food  containing  an 
excess — sometimes  very  large — of  combined,  and  especially,  free,  hydro- 
chloric acid.  If  the  stomach  is  washed  and  several  hours  later — nothing 
having  been  ingested  in  the  meantime — the  contents  of  the  organ  is  expressed 
this  will  be  found  to  consist  chiefly  of  gastric  juice,  where  normally  none 
should  be  present. 

Treatment.  The  neutralization  of  the  excessive  acidity  present  in  the 
stomach  by  means  of  the  alkaline  carbonates — sodium  bicarbonate  in  par- 
ticular— has  its  disadvantages,  the  resulting  sodium  chloride  from  the  com- 
bination of  sodium  bicarbonate  and  hydrochloric  acid  being  ready  for  forma- 
tion into  still  more  of  the  offending  substance;  however,  certain  observers 
claim  that  benefit  results  from  the  administration  of  considerable  doses  of 
sodium  bicarbonate — 10  to  30  grains  (0.66-2.0) — after  meals;  a  far  preferable 
antacid,  however,  is  heavy  magnesia  which  results  in  the  formation  of  mag- 
nesium chloride  which  acts  as  a  laxative  and  is  carried  off  from  the  body. 
Some  clinicians  prefer  to  give  it  with  sodium  bicarbonate,  but  it  is  better 
administered  in  a  combination  such  as  the  following:  ^  magnesii  ponderosi, 
gr.  X  (0.66);  pulveris  rhei,  gr.  v  (0.33);  extracti  belladonnae,  gr.  y^o"  (0.018); 
to  be  taken  ^  to  i  hour  after  each  meal.  Sodium  bicarbonate  in  amount 
equal  to  that  of  the  magnesia  may  sometimes  be  added  with  benefit.  Other 
useful  formulae  are:  I^  potassii  carbonatis,  magnesii  ponderosi  aa  gr.  xii 
(0.75);  extracti  belladonnae  gr.  -f'o  (0.018);  sacchari  lactis  gr.  xv  (i.o).  Misce 
et  signa,  to  be  taken  about  an  hour  after  meals.  Sodium  bicarbonate  may  be 
added  to  this  formula  also.  I^  sodii  bicarbonatis,  cretae  praeparatae,  mag- 
nesii carbonatis  aa  gr.  iii  (0.2).     Misce  et  signa,  to  be  taken  after  meals. 

Belladonna  is  said  to  lessen  the  secretion  of  the  gastric  juice  and  it  and 
atropine  are  also  useful  in  combating  the  severe  pain.  This  symptom  may 
be  rendered  less  distressing  by  various  narcotic  drugs  as  well,  codeine  and 
strontium,  ammonium  or  sodium  bromide  being  most  frequently  prescribed. 
Morphine  should  not  be  administered. 

Pain  which  resists  drug  treatment  "may  be  relieved  by  gastric  lavage,  which 
removes  the  hyperacid  contents  of  the  stomach.  To  the  last  of  the  water 
used  it  is  well  to  add  sodium  bicarbonate.  Washing  with  a  mixture  contain- 
ing bismuth  subgallate  and  bismuth  subcarbonate  of  each  i  drachm  (4.0) 
to  the  quart  (litre)  of  water  is  an  excellent  measure. 


384         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Intra-gastric  sprays  of  silver  nitrate  solution  (i-iooo)  are  said  to  have  the 
double  effect  of  lessening  the  secretion  and  relieving  the  discomfort.  Follow- 
ing this  procedure  the  stomach  should  be  washed  with  warm  water. 

The  drinking  of  considerable  quantities  of  Carlsbad  water,  natural  or 
artificial,  tends  to  lessen  the  production  of  hydrochloric  acid  by  the  stomach 
and-  in  hypochlorhydria  in  lithaemic  subjects  the  use  of  artificial  effervescent 
solutions  made  according  to  the  following  formulae  is  beneficial. 

a.  b. 

Sodium  bicarbonate 5ii  (8.0).  gr.  Ixxv  (5.0). 

Sodium  borate 5ss  (2.0).  gr.  xv  (i.o). 

Sodium  salicylate gr.  xxxvii  (2.5).  5ss  (2.0). 

Each  of  these  mixtures  is  to  be  added  to  a  quart  (litre)  of  ordinary  carbonic 
water  and  before  breakfast  a  half  tumbler  of  solution  a  is  to  be  taken.  After 
meals  a  half  tumbler  of  solution  b  should  be  drunk. 

Constipation  usually  yields  to  the  treatment  directed  at  the  neutralization 
of  the  acidity.  If  obstinate,  the  saline  waters,  abdominal  massage,  intestinal 
lavage  and  the  preparations  of  rhubarb  will  prove  effectual. 

Electricity  in  the  form  of  intra-gastric  galvanism  may  be  employed,  the 
anode  to  be  applied  inside  the  stomach,  which  should  be  partially  filled  with 
lukewarm  water,  while  the  cathode  is  placed  upon  the  epigastrium  or  back. 

Diet.  Certain  clinicians  advocate  a  diet  consisting  chiefly  of  proteid 
substances,  since  the  albuminous  foods  combine  with  the  excessive  hydro- 
chloric acid,  while  others  consider  much  carbohydrate  and  little  proteid  to  be 
better  adapted  to  the  gastric  condition  because  the  latter  class  of  foods  tends 
to  cause  increased  hydrochloric  acid  secretion,  but  the  proper  method  of 
deciding  upon  a  suitable  diet  in  these  cases  is  to  study  each  patient.  It  is 
probably  true,  however,  that  more  patients  will  do  well  upon  a  diet  principally 
of  proteid.  Of  the  meats,  beef,  mutton,  veal,  pork,  raw  or  cooked  ham  and 
fowl  are  allowable,  as  are  eggs,  Roquefort  and  Swiss  cheese,  cocoa  and  milk. 
Fats  are  not  contra-indicated  but  it  is  generally  considered  that  vegetables 
containing  large  amounts  of  starch  are  better  omitted.  Since  the  period  of 
starch  digestion  is  shortened,  owing  to  the  abnormally  early  secretion  of 
hydrochloric  acid  after  the  ingestion  of  food  in  this  condition,  starchy  foods 
should  be  eaten,  when  possible,  dextrinized,  toast,  zwieback  and  the  like 
being  preferable  to  plain  bread. 

Coffee,  beer  or  other  alcoholics'  should  be  forbidden  but  the  drinking  of 
considerable  quantities  of  alkaline  waters  with  meals  is  permissible  since  by 
this  means  the  excessive  gastric  juice  is  diluted. 

All  substances  likely  to  increase  the  secretion  of  gastric  juice,  such  as 
condiments,  spices,  fruits  containing  seeds  or  enveloped  in  skins,  etc.,  should 
not  be  eaten  and  the  food  should  be  taken  finely  divided  and  neither  very  hot 


HYPOCHLORHYDRIA.  385 

nor  very  cold.  The  patient  should  be  advised  to  masticate  thoroughly  so 
that  mouth-digestion  may  be  as  fully  accomplished  as  possible.  The  chewing 
between  meals  of  substances  calculated  to  excite  the  secretion  of  saliva  has 
been  advocated  with  the  idea  that  the  swallowing  of  this  secretion  in  large 
amounts  tends  to  neutralize  the  gastric  acidity,  but  is  of  slight  value. 

An  attack  of  pain  after  the  evening  meal  may  be  relieved  by  a  glass  of  warm 
milk,  a  cup  of  broth  containing  an  egg,  a  soft  boiled  egg  or  some  raw  ham 
finely  scraped.  Any  of  these  substances  takes  up  a  large  quantity  of  hydro- 
chloric acid.  \ 

The  treatment  of  paroxysmal  hyperchlorhydria  consists  in  the  employment 
during  the  attack  of  the  means  suggested  for  chronic  hyperacidity  on  p.  383, 
together  with  gastric  lavage  and  the  application  of  a  mustard  paste  or  hot 
water  bag  to  the  epigastrium.  Strontium  bromide  or  ammonium  bromide, 
J  drachm  (2.0)  three  times  a  day  is  said  to  shorten  and  to  lessen  the  fre- 
quency of  the  paroxysms.  The  general  management  of  the  condition  consists 
in  abstention  from  mental  over-activity  and  in  regulation  of  diet  and  exercise. 

Alcohol,  tobacco,  coffee  and  all  other  stimulants  shoiild  be  interdicted 
and  a  life  of  recreation  and  free  from  care  and  worry  should  be  ordered,  and 
exercise  out  of  doors — the  bicycle,  golf,  tennis,  riding,  swimming,  etc. — should 
be  advised.  Dietetically  and  otherwise  the  treatment  may  be  carried  out 
along  the  lines  laid  down  for  continuous  hyperchlorhydria. 

HYPOCHLORHYDRIA. 

Hypochlorhydria,  subacidity  or  hypochylia,  is  a  condition  of  the  stomach 
in  which  the  gastric  juice  contains  an  abnormally  small  amount  of  hydro- 
chloric acid  and  also  of  the  digestive  ferments.  It  exists  in  various  abnor- 
malities of  the  organ,  such  as  gastritis  and  cancer,  in  anaemic  conditions, 
during  the  infectious  diseases  and  in  neurotic  states;  the  subacidity  of  these 
last  conditions,  the  true  nervous  hypochylia,  occurs  in  hysteria,  locomotor 
ataxia,  etc. 

Entire  absence  of  hydrochloric  acid  which  is  denominated  achylia  gastrica 
occurs  in  hysteria  and  neurasthenia,  in  carcinoma,  and  as  a  result  of  the 
atrophy  of  the  gastric  glands  due  to  chronic  inflammations. 

The  symptoms  of  diminution  or  entire  absence  of  hydrochloric  acid  and 
gastric  ferments  are  not  ty-pical  and  the  condition  may  exist  for  long  periods 
without  causing  complaint  on  the  part  of  the  patient;  when,  however,  in  addi- 
tion to  the  secretory  disturbance,  the  motor  power  of  the  organ  is  impaired, 
the  consequent  fermentation  of  stagnant  food  results  in  distention,  eructations, 
sensations  of  weight  and  fullness  and  at  times  marked  gastralgia.  Diarrhoea 
may  be  present. 

The  diagnosis  can  be  made  only  on  chemical  examination  of  the  stomach 
25 


386         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

contents  withdrawn  after  a  test-meal.  This  shows  diminution  or  entire 
absence  of  both  free  and.  combined  hydrochloric  acid  and  of  the  gastric  fer- 
ments.    Lactic  acid  is  rarely  found  in  nervous  hypoacidity. 

The  treatment  of  both  hypochylia  and  achylia  consists  in  the  administration 
of  dilute  hydrocliloric  acid  to  supply  the  lack  of  this  substance  in  the  stomach. 
The  dose  should  be  regulated  with  regard  to  the  amount  present  in  the  gastric 
secretion.  When  the  acid  is  wholly  absent  as  much  as  15  to  20  drops  (i.o- 
1.33)  may  be  given  half  hourly  after  meals  until  3  doses  have  been  taken. 
It  must  be  plentifully  diluted  and  taken  through  a  tube.  The  administration 
of  pepsin,  pancreatin,  and  especially  of  fresh  pineapple  juice,  which  contains 
a  digestive  ferment,  may  supply  the  loss  of  the  normal  digestive  ferments. 

Loss  of  appetite  may  be  relieved  by  basic  orexin  and  by  gastric  lavage 
with  solutions  of  the  vegetable  bitters  such  as  gentian  or  quassia.  In  atony 
of  the  gastric  musculature  strychnine  nitrate  in  large  doses — gr.  -^^  to  -jV 
(0.002-0.003)  is  indicated  and  this  drug  also  exerts  a  favorable  action  upon 
any  co-existent  neurotic  condition.  Stagnated  and  decomposed  food  should 
be  washed  out  and  the  stomach  irrigated  with  a  disinfectant  solution  (see 
p.  352);  electricity  and  hydrotherapeutic  procedures  are  useful  adjuncts  to 
the  treatment. 

The  diet  should  be  adapted  to  the  digestive  capabilities  of  each  patient. 
Meat  need  not  be  interdicted,  in  fact  it  is  better  that  the  patient  eat  some 
meat,  this  should,  however,  be  taken  in  a  finely  divided  condition.  Green 
vegetables  and  pur^e  soups  may  be  taken;  fats  in  the  form  of  cream  and 
butter  are  allowable  unless  they  cause  fermentation.  Salty  substances  such 
as  anchovy  paste,  caviar,  etc.,  taken  before  meals  in  small  quantities,  increase 
both  the  appetite  and  the  gastric  secretion. 

CARDIOSPASM. 

Synonym      Cramp  of  the  Cardia. 

This  is  a  spasmodic  contraction  of  the  gastric  musculature  at  the  cardiac 
end  of  the  stomach  and  is  usually  the  result  of  some  irritation  such  as  hyper- 
acidity, or  distention  of  the  stomach  by  air  or  gas.  It  also  occurs  as  a  symptom 
of  neurasthenic  and  hysterical  conditions  and  very  rarely  as  a  true  neurosis 
of  the  motor  system  of  the  organ.  It  exists  in  an  acute  and  in  a  chronic  form; 
the  former  appears  paroxysmally  and  lasts  but  a  short  time,  the  latter  is  a 
serious  condition  and  one  difficult  of  management.  The  acute  variety,  when 
occurring  in  an  empty  stomach,  gives  no  symptoms;  on  a  full  stomach  it 
produces  a  spasmodic  and  cramp-like  pain  which  soon  passes;  if  food  or 
drink  is  taken  during  the  cramp  there  may  be  obstruction  to  deglutition. 
In  the  chronic  form  the  patient  may  also  have  difficulty  in  swallowing  and  feel 
that  the  food  stops  before  entering  the  stomach.    If  he  continues  to  eat  the 


PYLOROSPASM.  387 

oesophagus  gradually  fills  and  finally  the  food  is  regurgitated  little  changed 
and  containing  no  gastric  juice.  The  inability  of  food  to  reach  the  stomach 
brings  on  a  progressive  emaciation  which  is  likely  to  cause  suspicion  of  carci- 
noma, and  the  accumulation  of  ingesta  in  the  oesophagus  may  result  in  dilata- 
tion or  diverticulum  formation.  There  is  likely  to  be  obstruction  to  the 
passage  of  the  stomach  tube. 

Treatment.  This  consists  in  the  appropriate  treatment  of  any  co-existent 
inflammation  or  secretory  disorder  of  the  stomach.  The  food  should  be 
non-irritant,  easily  digestible  and  taken  in  finely  divided  form.  In  the  severer 
grades  of  this  condition  milk  diet  or  feeding  through  the  stomach  tube  may 
be  necessary  although  it  is  stated  that  at  times  solids  are  more  easily  swallowed 
than  liquids.  Any  constitutional  neurotic  condition  should  receive  proper 
treatment.  The  insertion  of  a  firm  tube  of  good  size  through  the  cardiac 
orifice  and  allowing  it  to  remain  in  place  for  a  half  hour  at  a  time  is  an  approved 
method  of  treatment.  Before  eating,  the  gastric  mucosa  at  the  cardia  may 
be  cocainized  by  a  small  sponge  fixed  at  the  extremity  of  a  stomach  tube  by 
means  of  a  thread  passed  through  the  tube.  The  sponge  should  be  saturated 
with  2-4  percent,  cocaine  hydrochloride  solution,  the  tube  passed  as  far  as 
the  cardia  and  the  cocaine  solution  expressed  by  pulling  the  thread.  An 
intra-gastric  spray  of  cocaine,  or  cocaine  and  menthol  solution  may  also  be 
employed  to  produce  anaesthesia.  The  use  of  the  galvanic  current  is  an 
excellent  measure  in  chronic  spasm;  the  anode  is  introduced  into  the 
cardia,  the  location  of  which  has  previously  been  ascertained  by  measure- 
ment, the  cathode  is  applied  to  the  back  of  the  neck  and  a  current  of  about 
25  milliamperes  is  employed  for  10  minutes;  the  anode  is  then  placed  over 
the  stomach  and  the  cathode  within  the  cardia  and  the  process  repeated. 

PYLOROSPASM. 

This  condition  is  analogous  to  cardiospasm,  but  takes  place  at  the  pyloric 
extremity  of  the  stomach.  It  occurs  in  excessively  acid  states  of  the  organ, 
accompanying  gastric  dilatation,  as  a  resiilt  of  the  action  of  caustics,  and  as  a 
concomitant  of  pyloric  ulcer  or  cancer. 

The  interference  with  the  passage  of  stomach  contents  through  the  pylorus 
results  in  stagnation  and  fermentation  and  finally  in  dilatation  with  the  accom- 
panying symptoms  of  these  conditions.  In  thin  subjects  the  gastric  peris- 
talsis may  be  visible  and  in  some  instances  reversed  peristalsis  with  vomiting 
takes  place. 

Treatment  consists  in  the  exhibition  of  sedatives,  such  as  the  bromides, 
strontium  bromide,  15  to  20  grains  (i. 0-1.33),  codeine  phosphate,  J  to  ^  a 
grain  (0.016-0.03)  or  extract  of  belladonna,  ^  to  ^  a  grain  (0.016-0.03)  three 
times  a  day.     Hydrated  chloral  may  be  used  but  is  dangerous  because  of  the 


388        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

possibility  of  establishing  the  habit.  The  spasm  may  be  controlled  by  the 
intra-gastric  cocaine  spray,  and  intubation  of  the  pylorus,  allowing  the  tube  to 
remain  in  place  for  about  10  minutes,  is  recommended.  The  galvanic  ctirrent 
may  be  used  as  described  under  the  treatment  of  cardiospasm.  All  food 
which  may  irritate  the  stomach,  and  over-burdening  the  organ  with  large 
amounts  of  food  should  be  avoided. 

GASTRIC  HYPERPERISTALSIS. 

Synonym.     Peristaltic  Unrest. 

This  is  a  condition  characterized  by  rapid  and  continuous  contractions  of 
the  stomach.  The  movements  are  most  marked  after  meals,  but  sometimes 
occur  when  the  stomach  is  empty  and  may  persist  through  the  night.  Little 
or  no  pain  is  present  but  the  patient  complains  of  uncomfortable  sensations 
referred  to  the  stomach.  Gastric  hyperperistalsis  is  the  result  of  an  increased 
irritability  of  the  sensory  or  motor  nerves  of  the  organ  due  to  a  reflex  result- 
ing from  gastric  hyperaesthesia  or  to  irritation  from  excessive  acidity,  fermenta- 
tion or  distention;  it  may  occur  with  pyloric  stenosis. 

The  contractions  may  be  felt  by  the  examiner's  hand  and  at  times  when 
very  active,  may  be  seen  as  well.  The  symptoms  are  loss  of  appetite,  eruc- 
tations, nausea  and  vomiting.  In  severe  instances  the  patient  may  lose  flesh 
and  strength  and  the  continuous  discomfort  brings  on  a  neurotic  condition.  At 
times  the  small  intestine  may  take  part  in  the  excessive  peristalsis  and  cause 
the  regurgitation  into  the  stomach  and  even  the  vomiting  of  intestinal  contents. 

Treatment.  The  drug  treatment  is  identical  with  that  of  pyloric  spasm 
and  the  patient  should  be  advised  to  lead  a  regular  and  quiet  life,  avoiding 
mental  and  physical  exertion.  Intra-gastric  galvanism  and  hydrotherapeutic 
procedures  are  useful  adjuvants.  Only  easily  digestible  foods  should  be 
allowed  in  order  to  avoid  all  irritation  of  the  stomach  and  possibility  of  dis- 
tention by  means  of  fermentation  products.  A  rest  cure  with  rectal  alimenta- 
tion continued  for  a  fortnight  may  bring  about  good  results  in  severe  instances. 

MERYCISM  OR  RUMINATION. 

Definition.  This  is  a  condition  in  which  the  patient  voluntarily  causes  his 
food  to  return  to  the  mouth  where  it  undergoes  further  mastication  and  is 
swallowed  again  or  expectorated. 

It  occurs  in  individuals  of  neurotic  habit  as  a  rule  and  in  marked  instances 
the  food  is  regurgitated  after  every  meal,  the  patient  often  asserting  that  the 
act  causes  pleasant  sensations. 

The  condition  of  the  gastric  secretions  is  not  uniform  but  a  subacidity 
seems  to  exist  in  most  patients. 


NERVOUS    ERUCTATION    OF    GAS.  389 

Treatment  consists  in  the  correction  of  secretory  disorders  by  the  use  of 
hydrochloric  acid  or  alkalies  as  the  case  may  be.  The  patient's  nervous 
and  general  condition  should  receive  attention  and  he  should  be  enjoined  to 
masticate  slowly  and  thoroughly.  He  should  be  encouraged  to  resist  the 
impulse  to  raise  his  food  and  to  combat  the  habit  with  the  utmost  strength 
of  his  wiU.  Bits  of  cracked  ice  taken  after  meals  are  said  to  be  useful  and 
intra-gastric  electricity  may  be  employed.  The  administration  of  10  grains 
(0.66)  of  quinine  sulphate  after  each  meal  may  break  the  habit  by  rendering 
the  food  unpleasantly  bitter. 

The  diet  of  these  patients  should  consist  chiefly  of  easily-digested  fluids 
and  semi-solids. 

NERVOUS  ERUCTATION  OF  GAS. 

This  symptom  is  often  seen  in  hysterical  and  neurasthenic  patients.  The 
gas  raised  is  usually  tasteless  and  consists  chiefly  of  swallowed  air,  and  various 
gastric  symptoms  may  or  not  be  co-existent.  The  belching  frequently  occurs 
in  paroxysms  but  at  times  is  almost  continuous. 

Treatment  consists  in  teaching  the '  patient  to  guard  against  swallowing 
air.  This  is  a  habit  which  a  little  thought  and  attention  on  his  part  can  stop; 
keeping  the  mouth  continuously  open  for  a  half  hour  or  so  at  a  time  may 
be  tried  for  air  cannot  be  swallowed  when  the  mouth  is  open.  The  neuras- 
thenic or  hysterical  condition  should  receive  general  treatment  to  which 
massage  and  hydrotherapeutic  measures  are  useful  adjuncts.  The  bromides, 
arsenic  and  belladonna  may  be  employed,  and  the  following  pill  may  be  found 
effectual :  I^  extract!  physostigmatis,  gr.  j^  (0.006);  extracti  belladonnae, 
gr.  ^  (0.012);  strychninae  sulphatis,  gr.  -^  (0.0015).  Signa;  one  pill  three 
times  a  day. 

Purinaemic  conditions  may  result  in  neurasthenia  and  when  such  are  accom- 
panied by  nervous  eructation  the  treatment  is  plainly  that  of  the  causative 
factor. 

GASTRIC  HYPERiESTHESIA. 

This  is  a  sensory  disturbance  of  the  stomach  in  which  the  ingestion  of  food 
results  in  pain  referred  to  the  organ,  at  times  so  great  as  to  cause  reluctance 
on  the  part  of  the  patient  to  eat.  Hysterical  individuals  may  assert  that 
only  certain  articles  of  food  cause  the  distress  while  others  may  be  eaten  with 
impunity.  This  neurosis  often  occurs  in  anaemic  and  chlorotic  conditions, 
after  periods  of  over-eating  or  indulgence  in  indigestible  foods  and  as  a  result 
of  sexual  or  alcoholic  excesses. 

Another  cause  is  hyperacidity  and  the  condition  may  also  exist  in  organic 
nervous  diseases  such  as  locomotor  ataxia. 


390         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Symptoms.  These  are  distress  after  eating  and  nausea,  often  followed  by 
vomiting.  When  the  stomach  is  empty  they  are  absent.  Often  pulsation  of 
the  aorta  is  complained  of  and  constipation  is  usually  present.  Diffuse 
tenderness  over  the  region  of  the  stomach  is  frequently  observed  and  other 
nervous  manifestations,  such  as  headache  and  various  neuralgias,  are  common. 
Examination  of  the  stomach  contents  reveals  nothing  characteristic. 

Treatment.  Attention  should  be  given  to  the  constitutional  condition, 
if  this  is  the  causative  factor,  and  a  rest  cure  is  frequently  effectual.  The 
pain  itself  may  be  controlled  by  hot  applications  and  the  use  of  an  intra-gastric 
spray  of  cocaine  and  menthol,  care  being  taken  to  control  the  amount  of  the 
former  drug.  Intra-gastric  galvanism  is  appropriate,  and,  when  the  intra- 
gastric electrode  cannot  be  used,  external  galvanism  with  the  electrodes  applied 
to  the  abdomen  may  be  employed.  Silver  nitrate  gr.  \  (0.016)  in  2  drachms 
(8.0)  of  peppermint  water  taken  in  water  a  half  hour  before  each  meal  has  been 
suggested,  and  the  bromides  and  codeine  may  produce  good  results. 

The  diet  should  at  first  be  of  milk  taken  a  small  quantity  at  a  time.  Later, 
as  the  condition  becomes  ameliorated,  eggs  and  semi-solids  may  be  allowed, 
and  finally  a  return  to  solid  food  may  be  permitted.  Later  massage,  hydro- 
therapeutic  measures,  moderate  exercise,  and  a  change  of  climate  are  to  be 
recommended. 

Alcohol,  tobacco  and  the  abuse  of  tea  and  coffee  should  be  forbidden. 

GASTRALGIA. 

Synonyms.     Gastrodynia;  Gastric  Neuralgia. 

This  is  an  affection  characterized  by  severe  paroxysmal  pain  referred  to 
the  stomach.  The  pain  may  be  localized  in  the  epigastrium  or  may  radiate 
to  any  part  of  the  abdomen  or  to  the  back.  It  occurs  in  motor  and  secretory 
neuroses,  and  in  various  other  gastric  lesions  such  as  ulcer  and  cancer,  in 
certain  nervous  diseases,  such  as  tabes  dorsalis,  during  infectious  diseases, 
especially  malaria,  in  nervous  and  hysterical  conditions  and  as  a  reflex  pain 
the  result  of  diseases  of  the  genito-urinary  organs,  particularly  in  women. 

Idiopathic  gastralgia  occxirs  in  chlorotic  and  anaemic  states,  in  convalescent 
conditions,  nephritis  and  various  toxaemias,  and  especially  in  incipient  pul- 
monary tuberculosis.  The  fact  that  it  often  manifests  itself  in  early  phthisis 
is  responsible  for  much  mistaken  diagnosis  and  treatment,  many  of  these 
patients  putting  themselves  in  the  hands  of  the  gastrologist  who  is  apt  to 
miss  the  true  causative  factor  of  the  condition. 

The  attacks  of  pain  usually  begin  suddenly  and  are  at  times  so  severe  as  to 
be  almost  unendurable,  perspiration  appears  upon  the  forehead,  the  pulse  is 
weak  and  may  be  faster  or  slower  than  normal.  There  may  be  suppression 
of  urine;  the  bowels  are  usually  constipated.     The  patient  is  much  prostrated. 


BULIMIA.  391 

As  the  severity  of  the  paroxysm  wanes  the  patient  begins  to  yawn,  belches  gas 
and  may  vomit. 

Treatment  consists  in  the  proper  management  of  the  underlying  cause 
when  this  can  be  ascertained.  If  no  cause  can  be  found  symptomatic  treat- 
ment must  be  instituted.  Various  analgesic  drugs  such  as  codeine  sulphate, 
^  grain  (0.03)  every  3  or  4  hours,  chloroform  water,  i  to  2  drachms  (4.0- 
8.0),  hydrated  chloral,  10  to  15  grains  (0.66-1.0),  hyoscyamus,  belladonna, 
etc.,  may  be  employed.  To  patients  with  cardiac  depression  compound  spirit 
of  aether  may  be  given  and  stimulation  by  means  of  aromatic  spirit  of  ammonia 
or  alcohol  may  be  necessary.  Acetanilide,  methyl  acetanilide  (exalgin), 
pyramidon  (a  derivation  of  antipyrine)  and  other  anti-neuralgics  are  recom- 
mended. In  instances  characterized  by  very  severe  pain  opium  may  be  em- 
ployed but  only  with  the  greatest  caution  lest  the  habit  become  formed. 
It  is  best  given  in  the  form  of  opium  and  belladonna  suppositories  or  hypo- 
dermatically  as  morphine  sulphate  in  connection  with  atropine.  These 
drugs  are  useful  only  in  lessening  the  patient's  pain  and  have  no  curative  effect; 
the  routine  employment  of  electricity  is  an  excellent  method  of  treatment. 
The  faradic  current  may  be  employed  but  the  galvanic  is  likely  to  accomplish 
better  results,  a  current  of  25  milliamperes  at  least,  being  necessary.  Large 
flat  electrodes  are  used,  they  are  moistened  in  water  as  hot  as  can  be  borne 
and  applied,  the  anode  to  the  epigastrium  and  the  cathode  to  the  inter-scapu- 
lar region.  Gastric  lavage  with  a  mixture  of  a  pint  (500.0)  of  camphor  water, 
and  bismuth  subgallate  5i  (4.0),  and  bismuth  subnitrate  5ii  (8.0)  is  said  to  be 
efl&cacious.  The  camphor  water  should  be  measured  as  it  returns  and  not 
more  than  an  ounce  (30.0)  allowed  to  remain  in  the  stomach. 

The  diet  should  consist  of  easily  digestible  foods.  Spices,  condiments, 
alcohol  and  excessive  amounts  of  tea  and  coffee  are  to  be  avoided. 

BULIMIA. 

Synonym.    Hyperorexia. 

Bulimia  is  a  condition  characterized  by  an  excessively  large  appetite.  It 
occurs  chiefly  in  persons  affected  with  functional  or  organic  nervous  disease 
such  as  hysteria,  epilepsy,  brain  tumors,  etc.,  with  intestinal  parasites,  uterine 
diseases  and  various  gastric  conditions.  The  hunger  comes  on  suddenly, 
at  times  even  directly  after  a  full  meal.  The  symptom  is  almost  irresistible 
and  if  it  is  not  appeased  palpitation  of  the  heart,  paleness,  faintness,  noises 
in  the  ears  and  gastric  pain  ensue.  In  some  patients  even  small  amounts  of 
food  sufl&ce  to  cause  a  disappearance  of  the  symptoms. 

Treatment  must  be  instituted  with  a  view  to  improvement  in  the  cause  of 
the  neurosis.  The  nervous  system,  the  genito-urinary  system,  the  stomach 
or  whatever  part  may  be  at  fault  must  receive  appropriate  treatment.     The 


392         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

bromides  are  useful,  Fowler's  solution  in  doses  increased  to  the  limit  of  tolerance 
is  recommended  and  the  administration  three  times  a  day  of  one  drachm  (4.0) 
of  camphorated  tincture  of  opium  or  of  2  drops  (0.13)  of  the  tincture  of  bella- 
donna in  2  or  3  drachms  (8.0-12.0)  of  simple  elixir  may  prove  effectual. 

Gastric  atony,  if  present,  may  be  treated  by  massage  and  strychnine,  and 
intra-gastric  faradism  should  achieve  good  results.  Lavage  with  warm  and 
cold  water  alternately  may  be  employed. 

ANOREXIA  NERVOSA. 

Nervous  anorexia  is  a  state  in  which  the  appetite  is  wholly  lost  and  the 
sense  of  hunger  unknown.  This  manifestation  may  last  for  months,  even 
while  the  digestive  apparatus  is  perfectly  normal  in  condition.  The  neurosis 
is  more  commonly  seen  in  female  subjects  and  is  predisposed  to  by  hysteric 
and  neurasthenic  conditions.  It  also  occurs  in  chlorosis  and  in  individuals 
addicted  to  the  abuse  of  drugs,  especially  alcohol,  tobacco  and  opium.  The 
degree  of  the  distaste  for  food  determines  the  prognosis  of  the  affection.'  Those 
subject  to  this  manifestation  become  progressively  anaemic  and  lose  flesh  and 
strength,  the  pulse  is  weak,  the  extremities  are  cold.  Insomnia  is  common. 
The  diagnosis  of  the  affection  is  simple  but  that  of  its  cause  is  more  difl5cult. 

Treatment  consists  in  combating  the  anaemia  and  the  nervous  condition  by 
appropriate  medication  and  in  properly  managing  any  co-existent  organic  dis- 
ease. The  rest  cure — putting  the  patient  away  from  outside  influences  and  in 
the  hands  of  a  trained  attendant,  and  over-feeding  him — is  an  excellent 
method;  in  this  connection  electrical  and  balneo-therapeutic  measures  and  mas- 
sage are  to  be  employed,  as  well  as  any  means  in  the  line  of  suggestion  that  the 
physician  may  be  able  to  use.  If  the  refusal  to  eat  is  carried  to  extremes  there 
should  be  no  hesitancy  in  employing  forced  feeding  by  gavage.  If  the  repug- 
nance to  taking  food  is  due  to  discomfort  attendant  upon  this  act  the  admin- 
istration of  sodium  bromide — 10  to  15  grains  (0.66-1.0) — before  meals  may 
overcome  this  disinclination.  Orexin — 5  to  10  grains  (0.33-0.66) — before 
such  meals  in  a  little  warm  bouillon  may  cause  a  distinct  increase  in  appetite 
and  the  following  formulae  may  be  found  useful:  I^  tincturae  cinchonas,  5ss 
(2.0);  acidi  sulphurici  diluti,  n^vii  (0.5);  syrupi  zingiberis,  5iiiss  (14.0).  Misce 
et  signa,  take  before  meals  through  a  tube  in  a  claret  glass  of  water.  I^  fluidex- 
tracti  condurango,  vr\xly  (3.0);  strychninae  sulphatis,  gr.  -^-q  (0.0015);  acidi 
hydrochlorici  diluti,  ^ix  (0.66);  elixiris  gentianse,  q.s.  ad  Sss  (15.00).  Misce 
et  signa,  take  in  wine  glass  of  water  before  each  meal  through  a  tube. 

CYCLIC  VOMITING. 

Definition.  Cyclic,  paroxysmal,  periodic  or  recurrent  vomiting  is  a  con- 
dition seen  in  children  and  characterized  by  the  sudden  appearance  of  violent 


aEMATEMESIS.  393 

and  persistent  emesis  which  may  persist  long  after  the  stomach  has  been 
entirely  emptied.  The  attacks  usually  appear  when  the  child  is  about  two 
years  old  and  recur  with  a  lessening  degree  of  frequency  as  puberty  approaches 
when  they  cease.  The  intervals  vary  in  different  patients,  being  from  a  few  weeks 
to  a  few  months,  and  at  times  the  vomiting  is  so  severe  and  continuous  as  to 
bring  about  a  condition  of  collapse  which  has  been  known  to  result  fatally. 
The  aetiology  of  this  condition  is  not  definitely  known  but  it  is  probable  that 
it  is  a  disorder  of  metabolism.  Both  acetone  and  diacetic  acid  have  been 
found  in  the  urine  preceding  or  during  the  attack. 

Treatment  at  times  wiU  be  found  to  have  little  effect  but  the  administration 
of  large  doses  of  sodium  bicarbonate — loo  to  125  grains  (6.66-8.33)  P^'^  ^^7 — 
is  the  most  approved  means  and  may  succeed  in  aborting  or  cutting  short 
the  paroxysm.  It  has  been  suggested  that  fats — except  fresh  butter — 
are  not  well  borne  by  patients  subject  to  this  manifestation  and  that  too  large 
a  carbohydrate  content  in  the  diet  may  produce  digestive  changes  which  favor 
the  occurrence  of  the  vomiting.  During  the  attack  it  is  better  not  to  attempt 
to  feed  the  patient  but  if  the  paroxysm  is  protracted  rectal  feeding  may  be 
instituted  and  at  all  times  it  is  well  to  administer  water  by  this  route  to  allay 
the  thirst — 6  to  8  ounces  (300.0-500.0)  4  or  5  times  a  day  being  sufficient 
quantity.  When  the  attack  has  ceased  the  first  foods  allowed  may  be  broths, 
small  amounts  of  cold  milk  and  lime  water,  equal  parts,  and  barley  water. 
Attention  should  be  given  to  the  patient's  general  hygiene  during  the  intervals 
of  the  paroxysms. 

HiEMATEMESIS. 

The  vomiting  of  blood  is  a  symptom  of  various  morbid  conditions  of  the 
stomach  and  has  been  discussed  at  length  in  the  sections  devoted  to  the  dif- 
ferent affections  in  which  it  occurs.  It  results  from  the  rupture  into  the 
viscus  of  blood-vessels  in  its  walls,  from  the  regurgitation  of  blood  from  the 
intestine  or  from  the  swallowing  of  blood — later  to  be  vomited — which  has 
been  extravasated  from  vessels  of  the  nose,  pharynx,  or  oesophagus.  That 
blood  may  be  raised  from  the  respiratory  tract,  swallowed  and  finally  vomited 
must  not  be  forgotten. 

Haematemesis  occurs  in  injuries  of  the  stomach,  either  from  outside  trauma- 
tism or  as  a  result  of  the  ingestion  of  caustic  substances,  in  neoplasms  of  the 
organ,  in  diseases  of  the  organ,  such  as  gastritis  of  any  kind,  ulcer,  etc.,  in 
diseases  of  other  organs,  notably  hepatic  cirrhosis,  in  malignant  forms  of  the 
infectious  diseases,  yellow  fever,  smallpox,  etc.,  and  in  constitutional  diseases 
such  as  purpura,  haemophilia  and  pernicious  anaemia.  Vomiting  of  blood 
has  been  observed  after  the  rupture  of  aneurysms  into  the  oesophagus. 

The  condition  of  the  blood  vomited  depends  upon  the  length  of  time  which 


394         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

it  has  lain  in  the  stomach.  If  fresh  it  may  be  bright  in  color  and  otherwise 
little  changed.  If  it  has  been  subjected  to  the  action  of  the  gastric  juice  it  is 
likely  to  be  dark  and  may  be  of  "coffee -ground"  appearance.  The  differ- 
entiation of  haematemesis  from  haemoptysis  may  generally  be  made  on  the 
following  points:  Vomited  blood  is  usually  dark  in  color,  not  frothy,  and 
often  is  acid  in  reaction,  while  blood  from  the  respiratory  tract  is  light  red 
or  pinkish,  is  likely  to  contain  an  admixture  of  air  and  is  consequently  frothy, 
and  is  alkaline  in  reaction.  In  haemoptysis  the  stools  are  not  "tarry," 
while  in  gastric  haemorrhage  the  blood  which  has  passed  through  the  pylorus 
appears  in  the  stools,  imparting  to  them  a  black  color. 

The  symptoms  of  gastric  haemorrhage  are  those  of  loss  of  blood  from  any 
other  part,  viz.,  paleness,  prostration,  rapid,  feeble  pulse,  subnormal  temper- 
ature, air  hunger,  depression,  faintness,  and  cold  clammy  skin.  Fortunately 
death,  from  this  cause  primarily,  seldom  occurs. 

The  treatment  of  haematemesis  has  been  fully  dealt  with  in  the  section 
relating  to  the  management  of  gastric  ulcer  (p.  365). 

DISEASES  OF  THE  INTESTINE. 
SIMPLE  ACUTE  CATARRHAL  ENTERITIS. 

Synonyms.     Acute  Diarrhoea;  Acute  Intestinal  Catarrh;  Acute  Ileo-colitis. 

Definition.  An  acute  inflammation  involving  the  small  intestine  and  at 
times  the  upper  portion  of  the  colon. 

.Etiology.  This  disease  is  more  common  during  the  hot  months  and  espe- 
cially in  children.  The  heat  is  not  so  much  a  direct  cause  as  it  is  a  predis- 
posing one,  since  it  diminishes  the  bodily  resistance  and  increases  the  suscep- 
tibility of  the  intestinal  tract  to  the  influences  of  over-eating  or  improper 
food.  Acute  intestinal  catarrh  often  follows  excessive  indulgence  in  food  or 
drink,  particularly  if  the  substances  taken  are  impure,  such  as  unripe  or 
decayed  fruit,  decomposed  food,  contaminated  drinking  water  or  the  like. 
The  ingestion  of  irritant  drugs  such  as  mercury  bichloride  or  arsenic  may 
cause  intestinal  inflammations  and  the  condition  is  also  predisposed  to  by 
any  sudden  chilling  of  the  body.  Excessive  or  diminished  secretion  of  bile 
may  be  mentioned  as  causes,  the  latter  since  it  may  favor  fermentation  by 
depriving  the  intestine  of  the  supposed  antiseptic  effect  of  this  fluid. 

Enteritis  often  accompanies  certain  of  the  infectious  diseases  and  is  pre- 
disposed to  by  conditions  of  congestion  of  the  intestine  such  as  occur  in  cardiac 
and  hepatic  lesions  and  by  inflammations  of  adjoining  structures  such  as  the 
peritonaeum.  Chronic  wasting  disease,  tuberculosis,  cancerous  states,  anaemia, 
etc.,  may  be  complicated  by  acute  diarrhoea. 

Pathology.     The  mucous  membrane  lining  the  intestine  is  first  congested, 


SIMPLE    ACUTE    CATARRHAL    ENTERITIS.  395 

red  and  swollen;  the  secretion  is  at  first  diminished  but  later  there  is  an  exces- 
sive production  of  mucus  with  exfoliation  of  the  epithelial  cells;  the  solitary 
follicles  are  h\-peraemic  and  swollen  and  may  become  filled  with  pus;  such 
tiny  abscesses  may  rupture  leaving  ulcerating  surfaces.  In  severe  forms 
of  the  inflammation  the  agminated  follicles  also  may  be  involved  in  like 
manner.     Chronic  inflammation  may  result  in  rare  instances. 

Symptoms.  Diarrhoea  is  the  most  characteristic  of  these.  The  evacua- 
tions at  first  consist  of  ordinary  faecal  matter,  but  as  they  continue  they  con- 
tain bile,  mucus,  and  finally  become  watery.  In  severe  instances  blood  may 
be  present.  They  vary  in  number  from  5  or  6  to  15  or  20  per  day,  and  may 
be  accompanied  by  colicky  pain  and  tenesmus.  They  are  likely  to  be  foul 
at  first  and  accompanied  by  gas,  later  they  may  lose  their  odor.  Loss  of 
appetite  is  the  rule  and  nausea  and  vomiting  may  be  present.  A  rise  of  tem- 
perature of  2  or  3  degrees  F.  may  accompany  the  diarrhoea,  and  thirst  and 
diminished  urine  are  noted  as  a  result  of  the  loss  of  water  tlirough  the  intes- 
tinal tract. 

Physical  examination  reveals  little  more  than  slight  diffuse  abdominal 
tenderness,  meteorism  and  gurglings  in  the  intestine. 

When  the  inflammation  is  localized  various  symptoms  may  call  attention 
to  probable  involvement  of  particular  portions  of  the  intestinal  tract.  If 
the  skin,  conjunctivae  and  urine  are  colored  with  bile  pigment  it  is  probable 
that  the  inflammation  particularly  affects  the  duodenum.  If  the  jejunum 
and  ileum  are  involved  to  the  exclusion  of  the  large  intestine  diarrhoea  is 
absent,  but  the  pain,  distention  and  other  symptoms  are  present;  the  diagnosis 
of  inflammations  affecting  this  portion  of  the  alimentary  tract  alone  is  diflicult 
and  of  little  practical  value.  When  the  morbid  condition  involves  both  the 
small  and  large  intestine  mucus  is  present  and  may  be  observed  distinct  and 
separate  from  the  faeces  which  may  contain  bits  of  undigested  food.  The 
diagnosis  of  acute  intestinal  catarrh  should  present  no  great  difficulties;  it 
may  be  differentiated  from  enteric  fever  by  its  short  duration,  lack  of  charac- 
teristic temperature  curve,  absence  of  exanthem  and  of  Widal  reaction.  The 
condition  is  not  a  serious  one,  recovery  under  proper  treatment  taking  place 
within  a  few  days. 

Treatment.  In  mild  instances  the  patient  need  not  be  confined  to  his  bed 
but  should  refrain  from  exertion  of  any  sort.  Certain  patients  need  no  treat- 
ment further  than  a  strict  milk  diet,  for  as  soon  as  the  intestine  has  by  its 
own  action  rid  itself  of  the  cause  of  the  inflammation,  spontaneous  recovery 
takes  place.  In  most  instances,  however,  it  is  better  to  aid  nature  by  admin- 
istering a  laxative  which  shall  hasten  the  passage  of  the  offending  substance. 
The  laxatives  most  often  used  are  calomel  and  castor  oil.  The  former  is  best 
given  in  doses  of  J  to  ^  a  grain  (0.016-0.03)  every  half  hour  until  6  doses  are 
taken,  it  exercises,  in  addition  to  its  pureative  action,  an  antiseptic  effect  upon 


396         DISEASES    OF    THE    DIGESTIV'E    SYSTEM    AND    PERITONEUM. 

the  intestine,  while  castor  oil,  which  should  be  given  in  single  dose  of  2  to  4 
drachms  (8.0-16.0),  has  the  advantage  of  a  slightly  constipating  after-effect. 
The  emptying  of  the  bowel  may  be  facilitated,  especially  in  children,  by  irri- 
gation of  this  viscus  with  warm  normal  saline  solution  by  means  of  a  rectal 
tube  or  soft  rubber  catheter  and  a  fountain  syringe. 

When  intestinal  astringents  or  antiseptics  are  necessary  on  account  of  the 
prolongation  of  the  diarrhoea,  any  of  the  salts  of  bismuth  may  be  given,  the 
subsalicylate — gr.  x  to  xx  (0.66-1.33)  every  4  hours — being  especially  effectual. 
Bismuth  naphtholate  (orphol)  5  to  15  grains  (0.33-1.0),  resorcinol — gr.  ii 
to  viii  (0.13-0.5) — or  phenyl  salicylate  (salol) — :gr.  ii  to  v  (0.13-0.33) — may 
also  be  employed.  If  the  diarrhoea  still  persists,  opium  in  sufficient  doses 
of  the  powder,  the  tincture  or  of  Dover's  powder,  as  suppositories  or  in 
the  form  of  an  opium  and  starch  enema — one  or  two  teaspoonsful  (4.0  to  8.0) 
of  starch,  i  to  2  grains  (0.065-0.13)  of  powdered  opium,  8  ounces  (240.0)  of 
warm  water,  should  be  given. 

For  the  constipation  resulting  from  the  use  of  opium  laxatives  need  not  be 
given  since  the  bowels  will,  as  a  rule,  move  normally  after  a  few  days.  The 
hypodermatic  administration  of  morphine  may  be  necessary  in  severe  in- 
stances when  frequent  vomiting  and  purging  preclude  the  exhibition  of 
opium  by  mouth  or  rectum. 

The  abdominal  pain  may  be  controlled  by  hot  or  cold  compresses. 

Diet.  During  the  first  day  or  two  of  the  attack  as  little  food  as  possible 
should  be  allowed  and  that  preferably  in  the  form  of  milk.  As  the  condition 
becomes  ameliorated  other  non-irritating  foods  such  as  bouillon,  soft  boiled 
eggs,  milk  toast,  etc.,  may  be  eaten,  to  be  followed  as  the  diarrhoea  ceases,  by 
sweetbreads,  calf's  brain,  scraped  beef,  meat  jellies,  the  white  meat  of  chicken 
and  mashed  potatoes.  Green  vegetables,  fruit  and  all  irritating  and  indigesti- 
ble articles  of  diet  should  be  omitted  from  the  diet  for  some  time. 

CHRONIC  CATARRHAL  ENTERITIS. 

Synonyms.  Chronic  Diarrhoea;  Mucous  Colitis;  Chronic  Entero-colitis; 
Ulcerative  Colitis. 

Definition.  A  chronic  catarrhal  inflammation  of  the  small  and  large  intes- 
tine, characterized  by  the  excessive  production  of  mucus,  and  at  times,  the 
development  of  ulcers. 

.Etiology.  This  disease  may  follow  attacks  of  acute  entero-colitis  or  of 
dysentery.  The  affection  may  occur  primarily,  and  it  is  predisposed  to  by 
cardiac  lesions,  hepatic  cirrhosis  or  any  other  condition  attended  by  chronic 
hyperaemia  of  the  digestive  tract,  by  conditions  of  feeble  nutrition,  purin- 
gemic  states,  and  chronic  wasting  diseases  such  as  anaemia,  nephritis  or  phthisis. 
It  may  follow  the  infectious  diseases,  notably  malaria  and  cholera. 


CHRONIC    CATARRHAL    ENTERITIS.  397 

Pathology.  At  first  the  pathological  state  is  that  of  acute  catarrhal  enteritis ; 
these  lesions  become  permanent  and  in  marked  instances  ulceration  of  the 
lymph  follicles  takes  place  with  consequent  haemorrhage,  and,  when  the 
ulcers  heal,  cicatricial  contractions  which  may  result  in  stenosis.  Pigmented 
spots  in  the  diseased  mucous  membrane  are  sometimes  observed  and  the 
destruction  of  the  intestinal  glands  by  the  inflammation  may  result  in  atrophy 
of  the  mucous  membrane  and  at  times  of  the  muscular  and  peritonaeal  coats 
of  the  bowel. 

Symptoms.  While  diarrhoea  is  the  rule  in  acute  entero-colitis,  in  the  chronic 
form  of  this  inflammation  this  is  not  the  case.  The  bowels  may  be  consti- 
pated, there  may  be  diarrhoea  or  there  may  be  an  alternation  of  these  condi- 
tions. A  fairly  constant  symptom  is  the  presence  of  mucus  in  the  movements 
from  the  bowels.  This  mucus  is  variable  in  quantity,  from  a  small  amount 
mixed  with  the  faecal  matter  to  large  masses  discharged  in  the  form  of  casts 
of  the  intestine.     If  ulceration  exists  there  may  blood  in  the  stools. 

The  type  of  the  disease  characterized  by  the  passage  of  casts  of  the  bowel 
is  seen  usually  in  neurotic  women.  Constipation  is  usually  present  and  at 
intervals  stools  of  the  type  described  above  are  passed,  accompanied  by  tenes- 
mus and  abdominal  pain  and  tenderness. 

Subjective  symptoms  may  be  wholly  absent  in  chronic  entero-colitis,  the 
appetite  and  gastric  digestion  are  often  good  but  there  are  at  times  abdominal 
discomfort  and  flatulence. 

Physical  examination  may  reveal  nothing  characteristic,  although  some- 
times tympanites  may  be  detected.  When  the  intestinal  contents  is  fluid 
palpation  may  elicit  gurglings  and  in  the  type  of  the  disease  of  which  consti- 
pation is  a  feature  the  hard  faecal  masses  may  be  made  out. 

The  course  of  the  disease  is  often  long  drawn  out  and  the  patient  may  be  ap- 
parently weU  save  for  his  intestinal  symptoms.  Other  patients  become  gradu- 
ally emaciated  and  may  die  from  exhaustion  rather  than  from  the  disease  itself. 

The  prognosis  as  regards  life  is  good  but  as  to  recovery,  especially  in 
instances  of  long  standing,  it  is  distinctly  bad. 

Treatment  of  this  disease  is  unsatisfactory,  consequently  many  drugs  have 
been  recommended  as  useful.  Of  these  silver  nitrate  may  be  mentioned 
first.  Its  dosage  is  \  grain  (0.016)  three  times  a  day,  or  it  may  be  given  in 
I  to  1,000  aqueous  solution  in  doses  of  2  or  3  drachms  (8.0-12.0)  three  times 
a  day.  Other  metallic  astringents  such  as  copper  sulphate,  J  grain  (0.016), 
lead  acetate,  2  grains  (0.132),  or  zinc  sulphate,  2  to  4  grains  (0.132  to  0.25) 
may  be  employed.  Other  drugs,  given  with  the  idea  of  lessening  the  diarrhoea 
by  means  of  inhibiting  the  fermentive  and  putrefactive  processes  going  on  in 
the  intestine,  may  be  mentioned  almost  without  number.  The  best  of  these 
are  the  bismuth  salts,  especially  bismuth  naphtholate  (orphol),  5  to  15  grains 
(0.33-1),  bismuth  tribromophenolate,  8  grains  (0.5)  and  bismuth  tetraiodo- 


398         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

phenolphthaleinate,  5  to  8  grains  (0.33-0.5).  The  subsalicylate,  the  sub- 
gallate  and  the  subnitrate  may  also  be  employed  in  doses  of  10  grains  (0.66) 
or  more,  frequently  repeated. 

The  vegetable  astringents  are  less  effective  than  the  bismuth  salts  but  in 
view  of  their  former  popularity  may  be  mentioned.  What  action  they  exert, 
for  we  now  know  that  they  do  not  act  as  astringents  when  introduced  into  the 
alimentary  tract,  is  due  to  their  tannic  acid  content.  Of  these  calumba, 
catechu,  rhatany,  campeachy  wood,  and  tannic  acid  may  be  mentioned. 
Tannalbin,  tannocol  and  tannigen  in  doses  of  8  to  15  grains  (0.5-1.0),  as 
well  as  the  calcium  salts — the  phosphate,  carbonate  and  salicylate — given 
in  solution  in  carbonated  water,  may  be  employed.  Goto — the  powder  in 
dosage  of  10  grains  (0.66),  or  as  cotoin,  J  to  i  grain  (0.032-0.065) — is  used 
empirically. 

Neurotic  diarrhoeas  due  to  hysteria,  the  symptom  complex  of  neurasthenia, 
migraine,  and  the  climacteric  require  not  only  careful  management  based 
on  the  underlying  cause  but  call  for  a  further  word  of  comment.  The  best 
results  are  obtained  from  the  persistent  use  of  the  bromides,  preferably  stron- 
tium bromide  (free  from  the  barium  salts),  60  to  90  grains  (4.0-6.0)  daily. 
After  3  days  this  may  be  diminished  in  quantity  and  the  solution  of  potassium 
arsenite  commenced,  3  drops  (0.2)  thrice  daily  and  increased  i  drop  (0.065) 
per  day  until  slight  untoward  symptoms  supervene. 

Nephritic  or  uraemic  diarrhoea  should  be  recognized  as  a  salutary  effort  of 
the  organism  to  rid  itself  of  the  poisons  whose  effects  we  characterize  as 
"uraemia."  The  proper  method  of  dealing  with  this  condition  is  the  admin- 
istration of  a  high  intestinal  irrigation  of  normal  sodium  chloride  solution, 
in  quantity  a  gallon  (4  Utres)  of  a  temperature  of  112°  F.  to  116°  F.  (44-5°  to 
46.5°  C.)  through  a  rectal  tube,  inserted  at  least  12  inches,  the  reservoir  be- 
ing elevated  about  3  feet.  If  the  chronic  nephritis  is  predominatingly  paren- 
chymatous, the  sodium  chloride  should  be  replaced  by  sodium  bicarbonate. 
Intestinal  irrigation  will  free  the  bowel  from  irritating  contents,  wiU  enable 
the  kidneys  to  functionate  normally  and  will  stimulate  the  heart. 

Purinaemic  diarrhoeas  are  best  combated  by  60  grains  (4.0)  daily  of  saligenin 
tannate,  regulation  of  the  diet  and  inhibition  of  intestinal  fermentation  by 
intestinal  antiseptics  until  the  proteid  metaboUsm  is  re-established  upon  a 
satisfactory  basis. 

Malarial  diarrhoea  is  best  treated  by  arsenic,  methylthionine  hydrochloride 
(methylene  blue)  or  a  combination  of  extract  of  ergot,  2  grains  (0.13),  berberine 
sulphate  i  grain  (0.065)  with  piperine  ^  grain  (0.032)  4  times  daily. 

In  patients  who  have  survived  the  acute  onset  of  cholera,  a  diarrhoea  fre- 
quently persists.  This  is  best  treated  by  bismuth  tribromophenolate,  90  to 
120  grains  (6.0-8.0)  daily.  In  addition  dried  suprarenal  extract,  5  grains 
(0.33)  3  times  a  day  will  assist  in  restoring  the  vascular  tone. 


CHRONIC    CATARRHAL    ENTERITIS.  399 

If  bile  pigment  is  present  in  the  stools  the  disturbance  is  presumably  high 
in  the  intestine  and  a  combination  of  salicylic  acid,  6  grains  (0.40)  with 
the  same  amount  of  acid  sodium  oleate,  with  4  grains  (0.25)  of  phenolphthalein 
and  J  grain  (0.032)  of  menthol,  given  once  daily  for  several  days  will  disinfect 
the  bile  and  remove  this  cause  of  intestinal  indigestion. 

The  constipation  occurring  in  chronic  entero-colitis  must  never  be  allowed 
to  persist  and  should  be  combated  by  mild  rather  than  drastic  measures. 
Enemata  of  warm  water,  castor  oil,  calomel  or  laxative  waters  such  as  Hunyadi, 
Apenta,  etc.,  are  the  best  means  of  controlling  this  symptom.  Faecal  impac- 
tions are  best  relieved  by  softening  them  by  quart  (litre)  injections  of  warm 
olive  oil,  the  patient  being  in  the  knee-chest  position,  or  drachm  (4.0)  doses 
of  arsenic-free  sodium  phosphate  twice  daily  by  mouth;  y^^  of  a  grain 
(0.0006)  of  physostigmine  salicylate  3  times  a  day  will  enable  the  intestinal 
muscularis  to  recover  its  tone. 

Opium  is  admissible  in  the  treatment  of  cloronic  diarrhoea  only,  when  the 
alimentary  canal  has  been  thoroughly  emptied,  to  check  excessive  peristalsis. 
It  should  be  given  hypodermatically,  as  morphine,  in  substantial  doses,  and 
not  repeated.  A  prescription  for  opium,  or  any  of  its  preparations  or  alkaloids, 
should  never  be  entrusted  to  patients  of  the  nervous  type.  There  is  too 
great  danger  of  habit  formation. 

The  extract  of  denarcotized  opium  and  extract  of  belladonna  have  been 
recommended  as  useful  in  the  relief  of  the  abdominal  pain  from  which  some 
patients  suffer  but  both  these  drugs  should  be  employed  with  utmost  caution, 
the  former  on  account  of  the  danger  of  causing  the  habit,  the  latter  lest  toxic 
symptoms  be  induced. 

Treatment  by  means  of  colonic  irrigation  is  effectual  when  the  chief  seat 
of  the  inflammation  is  the  large  intestine.  A  soft  rubber  rectal  tube  passed 
high  into  the  bowel  and  attached  to  a  fountain  syringe  or  a  large  funnel 
should  be  used.  Various  solutions  have  been  employed  in  this  connection, 
those  preferable  being  silver  nitrate  1-2  to  1,000,  boric  acid  i  to  100,  sali- 
cylic acid  2  to  100,  tannin  2-4  to  1,000,  zinc  sulphate  3  to  1,000  and  mercury 
bichloride  i  to  15,000.  The  last  is  irritating  and  if  absorbed  is  likely  to  pro- 
duce mercurial  intoxication,  consequently  it  should  be  administered  with 
great  caution. 

Diet.  By  far  the  best  diet  for  chronic  entero-colitis  is  milk,  but  it  cannot 
be  continued  indefinitely.  The  author  reserves  its  use  for  between  meals  and 
at  bed  time.  The  first  choice  is  a  properly  peptonized  milk,  not  taken  too 
cold.  For  the  meals  clear  meat  soups,  gruels,  eggs,  poached  on  toast,  soft- 
boiled  or  raw,  fresh  butter,  sweetbreads,  calf's  brain,  rare,  grilled  or  broiled 
steak  or  lamb  chops,  fresh  chopped  beef,  with  J  drachm  (2.0)  of  dilute  hydro- 
chloric acid  to  each  2  ounces  (60.0),  oysters  and  fish,  toast,  hard  rolls,  mashed 
potatoes  and  macaroni,  will  carry  the  patient  well  toward  the  time  when  a 


400        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

regular  mixed  diet  may  be  resumed.  To  be  avoided  are  fruits,  raw  or  sour, 
cooked  or  sweetened,  succulent  vegetables,  fat  meats,  all  highly  seasoned  and 
indigestible  foods,  foods  leaving  much  residue,  and  sugar.  All  dishes  should 
be  properly  cooked  and  prepared  as  simply  as  possible  in  every  way. 

Mineral  waters  seem  to  have  a  certain  influence  upon  chronic  intestinal 
catarrhs.  The  waters  of  Carlsbad  and  Vichy  have  a  considerable  vogue 
among  European  clinicians  and  the  waters  of  Saratoga  and  of  the  Virginia 
hot  springs  of  our  own  country  may  prove  quite  as  beneficial.  Water  cures 
at  home  are  seldom  as  beneficial  as  when  taken  at  the  springs  for  the  mode 
of  life,  regular  diet  and  exercise  at  these  resorts  has  an  additional  favorable 
action  upon  the  lesion. 

Aside  from  sojourns  at  spas,  other  changes  of  climate  and  scene  may  benefit 
the  patient. 

Hydrotherapeutic  procedures  have  a  place  in  the  management  of  chronic 
diarrhoeas  and  a  course  of  cold  water  treatment  at  an  institution  frequently 
acts  favorably.  Diarrhoeas  from  cold  almost  invariably  may  be  relieved  by 
the  daily  use  of  a  morning  cold  bath.  The  bath  should  commence  with  a  tem- 
perature of  88°  F.  (31.1°  C),  and  be  taken  cooler  by  a  degree  or  so  each  morn- 
ing until  68°  F.  (20°  C.)  or  even  58°  F.  (14.5°  C.)  is  reached.  A  5  minute 
bath  followed  by  a  brisk  rubbing  with  a  rough  towel  results  in  a  vigorous 
reaction,  and  the  morning  bath  not  only  soon  becomes  a  therapeutic  necessity 
but  a  luxury  as  well.  In  addition  an  abdominal  bandage  of  flannel  should 
be  constantly  worn.  Wet  abdominal  binders  and  hot  or  cold  compresses 
are  often  useful  adjuncts  to  treatment. 

CHOLERA  MORBUS. 

Synonyms.     Cholera  Nostras;  Sporadic  Cholera. 

Definition.  An  acute  inflammation  of  the  stomach  and  intestines  charac- 
terized by  profuse  emesis,  diarrhoea  and  severe  abdominal  cramps. 

.Etiology.  No  micro-organism  has  yet  been  proven  tcsbe  the  specific  cause 
of  this  disease  although  it  is  possible  that  it  may  be  of  bacterial  origin.  Until 
its  specific  cause  is  isolated  we  must  consider  it  to  be  the  result  of  the  ingestion 
of  impure,  decomposing  or  indigestible  articles  of  food,  such  as  decayed  or 
unripe  fruit,  fish,  salads,  etc.  Attacks  of  cholera  morbus  are  most  frequent 
during  the  hot  months  and  seem  to  be  predisposed  to  by  exposure  to  draughts 
while  the  body  is  over-heated. 

Pathology.  The  morbid  conditions  found  in  fatal  instances  of  cholera  mor- 
bus resemble  too  closely  those  of  acute  enteritis  to  need  separate  description. 

Symptoms.  The  onset  of  cholera  morbus  frequently  takes  place  in  the 
night.      The  patient  is  seized  without  warning  with  nausea,  followed  by 


CHOLERA    MOEBUS.  40I 

vomiting,  profuse  diarrhoea  and  severe  abdominal  cramps.  The  vomitus 
consists  at  first  of  the  stomach  contents  followed  by  bile  and  later  by  watery 
fluid.  The  stools  are  often  so  frequent  as  to  be  almost  without  interval, 
at  first  they  are  of  the  faecal  matter  contained  in  the  bowel  but  soon  become 
very  loose  and  watery.  A  rise  of  temperature  is  infrequent.  Thirst  due  to 
the  rapid  loss  of  water  is  marked.  The  pain  is  abdominal,  paroxysmal  and 
colicky;  the  muscles  of  the  Hmbs  later  become  painful;  in  severe  instances 
the  patient  may  fall  into  a  state  of  collapse,  with  marked  bodily  weakness, 
cold,  clammy  skin  and  weak  and  rapid  heart  action. 

Death  may  supervene  in  rare  instances  but  recovery  from  the  acuity  of 
the  attack  within  half  a  day  is  the  rule.  The  depression,  weakness  and 
irritability  of  the  digestive  tract  may  last  for  a  few  days  longer. 

Treatment.  Since  the  train  of  symptoms  known  as  cholera  morbus  is  the 
result  of  some  irritating  substance  in  the  gastro-intestinal  tract  the  first  indi- 
cation in  treatment  is  to  get  rid  of  the  cause  of  the  offence.  This  may  be 
done  by  administering  calomel  in  doses  of  \  grain  (0.016)  every  |  hour  until 
6  doses  have  been  taken,  or  castor  oil  ^  ounce  (15.0).  In  patients  with 
marked  and  frequent  vomiting  it  may  be  impossible  for  medication  given  by 
mouth  to  be  retained;  here  the  most  approved  method  of  cleansing  the 
intestine  is  by  high  rectal  irrigations  of  warm  water. 

The  severe  pain  may  be  controlled  by  the  application  of  counter-irritation 
by  means  of  the  mustard  or  flax-seed  poultice  or  a  capsicum  plaster  to  the 
abdomen.  These  should  be  carefully  watched  lest  they  cause  blisters.  When 
relief  is  not  brought  about  by  these  means  the  hypodermatic  injection  of 
morphine  may  become  necessary  but  this  remedy  should  be  used  with  the 
greatest  caution. 

In  the  later  stages  of  an  attack  the  use  of  a  prescription  such  as  the  following 
may  be  indicated:  I^  acidi  sulphurici  aromatici,  rr^vi  (0.4);  extracti  haema- 
toxylon,  n\vi  (0.4) ;  spiritus,  chloroiormi  rrLxii  (0.8) ;  fluidextracti  ipecacuanhae, 
Ti\iii  (0.2);  syrupi  zingiberis,  q.  s.  ad  3i  (4-o)-  Misce  et  signa,  one  dose  every 
2  hours. 

The  marked  thirst'  must  be  relieved  by  supplying  water  to  the  tissues  either 
by  high  rectal  enemata  of  normal  saline  or  by  hypodermatoclysis  of  the  same 
solution.  The  latter  process  consists  in  allowing  a  pint  Q  litre)  or  more  of 
saline  to  run  into  the  tissues  through  a  needle  attached  to  an  irrigation  appa- 
ratus and  plunged  into  the  thigh  or  buttock,  the  skin  of  which  has  been  previ- 
ously sterilized  -and,  if  advisable,  anaesthetized  by  means  of  an  ethyl  chloride 
or  aether  spray.  This  quantity  6f  the  solution  will  be  quickly  absorbed  and 
the  procedure  may  be  repeated  if  necessary. 

For  the  vomiting  the  patient  should  te'given  cracked  ice  to  hold  in  the 
mouth,  sips  of  iced  champagne  or  carbonated  waters.  The  tendency  to 
collapse  necessitates  the  exhibition  of  h}'podermatic  stimulation,  strychnine, 
26 


402         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

camphor  and  aether,  etc.,  the  apphcation  of  heat  to  the  extremities  or  wrapping 
the  body  in  a  hot  sheet. 

Diet.  During  the  acuity  of  the  attack  and  for  a  day  or  more  after,  the  less 
eaten  the  better.  As  the  vomiting  ceases  the  patient  may  begin  to  take  small 
quantities  of  milk  and  lime  water  or  milk  mixed  with  a  carbonated  mineral 
water  and,  as  progress  toward  recovery  is  made,  soups,  toast,  soft  eggs,  etc., 
may  be  allowed,  to  be  gradually  followed  by  a  return  to  ordinary  diet. 


DIARRHCEAS  OF  CHILDREN. 
Acute  Gastro-enteritis. 

Synonyms.     Summer  Diarrhoea;  Gastro-intestinal  Catarrh. 

Definition.  An  acute  catarrhal  mflammation  of  the  gastro-intestinal 
tract  characterized  by  vomiting,  diarrhoea  and  a  febrile  movement. 

.Etiology.  The  specific  cause  of  this  disease  is  probably  bacterial.  Various 
micro-organisms  have  been  considered  to  have  a  part  in  the  production  of 
this  condition,  namely  the  colon  bacillus,  the  streptococcus,  the  staphylococcus, 
the  bacillus  pyocyaneus,  the  bacillus  proteus  and  Shiga's  bacillus.  The 
disease  is  predisposed  to  by  teething,  hot  weather,  unhygienic  surroundings 
and  poor  bodily  condition.  The  exciting  cause  seems  usually  to  be  improper 
feeding,  either  in  quantity  or  quality.  Not  only  bottle-fed  babies  are  subject 
to  the  infection  but  those  fed  on  mother's  milk  are  often  attacked,  since  im- 
proper diet,  mental  excitement,  etc.,  are  capable  of  materially  changing  the 
lacteal  secretion  and  thus  causing  the  digestive  disturbance. 

Pathology.  The  gross  appearance  except,  for  the  presence  of  excessive 
mucus,  is  little  changed.  The  mucous  lining  of  the  gastro-intestinal  tract  may 
either  be  pale  or  hyperaemic  and  the  solitary  and  agminated  follicles  of  the 
small  intestine  may  be  swollen.  Patches  of  congestion  may  be  observed  in 
the  large  intestine.    The  intestinal  walls  are  not  thickened. 

Symptoms.  The  disease  occurs  in  two  chief  types,  the  mild  and  the  severe. 
In  the  former  the  onset  is  gradual  with  symptoms  of  indigestion,  little  or  no 
rise  of  temperature,  restlessness  and  fretfulness;  the  stools  become  more  fre- 
quent, are  diarrhceal  in  character,  greenish,  yellowish  or  brownish  in  color, 
of  bad  odor  and  contain  undigested  food;  later  mucus  appears. 

In  the  second  type  the  onset  may  be  gradual,  with  symptoms  of  digestive 
disturbance,  or  sudden,  with  a  rapid  rise  of  temperature — 102°  to  105°  F. 
(38.9°  to  40.5°  C.) — hot  dry  skin,  restlessness,  and  vomiting.  There  may  be 
convulsions  or  stupor.  The  thirst  is  often  extreme.  The  vomitus  consists 
first  of  undigested  food,  and  if  emesis  continues  after  the  stomach  has  become 
empty,  mucus  or  bile  may  be  vomited.     In  certain  patients  the  vomiting  may  be 


ACUTE    GASTRO-ENTERITIS.  403 

wholly  absent.  The  diarrhoea  may  not  appear  for  a  number  of  hours  after 
the  onset  of  the  attack.  The  stools  are  at  first  of  feecal  matter  and  are  accom- 
panied by  colicky  pains  and  gas;  later  they  become  thin,  watery  and  foul;  in 
color  they  are  grayish,  greenish  or  brownish.  They  contain  mucus  after  a 
few  days  and  may  be  as  many  as  15  or  20  during  the  24  hours.  The  child 
rapidly  becomes  weak  and  emaciated;  the  disease  may  prove  rapidly  fatal  or 
the  symptoms  may  abate  and  the  condition  become  subacute.  Relapses  are 
not  rare  and  an  entero-colitis  may  ensue. 

Treatment.  Prophylaxis,  in  view  of  the  probable  infectious  character  of 
the  disease,  consists  in  careful  attention  to  the  stirroundings  and  hygiene  of 
infants,  especially  during  the  summer,  the  immediate  washing  or  disinfection 
of  all  soiled  napkins,  and,  above  all,  proper  feeding,  the  use  of  boiled  water 
for  drinking  purposes  and  the  boiling  of  bottles  and  nipples — in  the  case  of 
artificially  fed  infants — previous  to  their  use  on  every  occasion.  Breast 
feeding  should  be  encouraged  and  mothers  advised  against  weaning  during 
the  summer. 

The  treatment  of  the  attack  proper  consists  in  measures  calculated  to  reheve 
the  digestive  tract  of  its  irritating  and  toxic  contents.  If  the  vomiting  is  per- 
sistent the  stomach  should  be  washed  by  means  of  a  soft  rubber  catheter  of 
appropriate  size  attached  to  a  rubber  tube  of  larger  calibre  and  a  funnel.  The 
lavage  should  be  continued  until  the  water  returns  clear  and  it  is  wise  to  leave 
a  little  water  in  the  stomach.  If  the  vomitus  has  been  very  acid  a  little  sodium 
bicarbonate  may  be  added  to  the  water  left  behind.  In  children  who  struggle 
against  the  stomach  tube  full  draughts  of  boiled  water  may  be  substituted 

The  small  intestine  should  be  relieved  of  its  contents  by  cathartics.  When 
vomiting  is  not  a  feature,  castor  oil,  2  drachms  (8.0),  may  be  given  to  a  child  of 
I  year  while  older  children  may  take  up  to  J  ounce  (15.0).  Calomel  in  divided 
doses  of  J  to  ^  a  grain  (0.016-0.032)  should  be  given  every  half  hour  up  to 
6  doses.  The  tablets  may  be  dissolved  in  a  teaspoonful  of  boiled  water  and 
are  willingly  taken. 

The  colon  should  be  irrigated  with  warm  normal  saline  solution.  Two  quart  s 
(litres)  should  be  used  and  given  through  a  soft  catheter  passed  high  into  the 
bowel.  This  procedure  should  be  carried  out  twice  or  tlirice  during  the  first 
day  of  the  attack  and  once  a  day  thereafter.  Drugs  are  often  unnec- 
essary but  should  they  be  indicated  bismuth  subgallate  in  doses  of  3  or  4 
grains  (0.2-0.25)  may  be  given  to  a  year  old  child  every  3  hours  or  phenyl 
salicylate  (salol)  in  doses  of  i  to  2  grains  (0.065-0.13)  may  be  administered. 
Antacids,  such  as  lime  water,  milk  of  magnesia  or  chalk  mixture,  are  often 
useful  when  hyperacidity  of  the  stomach  with  fermentation  is  present. 

For  patients  with  marked  prostration  stimulation  is  necessary  in  the  form  of 
whiskey  or  brandy  given  frequently  in  small  amounts  fully  diluted.  A  half 
ounce  (15.0)  in  divided  doses  during  the  24  hours  is  not  too  much  for  a  child 


404         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

of  I  year.  Hot  mustard  baths  and  applications  of  heat  are  useful  and  if  the 
diarrhoea  has  been  profuse  enough  to  deprive  the  system  of  a  large  amount 
of  water,  this  should  be  supplied  by  rectal  irrigations  or  by  hypodermatoclysis 
of  warm  normal  saline  solution. 

Diet.  Too  great  emphasis  cannot  be  laid  on  the  statement  that  no  food 
should  be  given  for  at  least  24  hours,  or  for  even  longer  periods,  should  the 
vomiting  continue;  cold  water  should  be  supplied,  however,  and  thin  barley 
water  or  albumin  water  (the  white  of  one  egg  in  8  ounces  (250.0)  of  boiled 
water)  to  which  a  little  brandy  has  been  added,  are  allowable.  If  these  are 
refused  the  stomach  should  be  allowed  to  rest. 

Usually  after  24  hours  the  child  may  be  nursed,  but  for  not  longer 
than  2  to  3  minutes,  at  intervals  of  at  least  4  hours.  In  the  intervals  barley 
or  albumin  water  may  be  given.  Gradually  the  intervals  between  breast 
feeding  may  be  lessened  and  the  length  of  the  nursing  prolonged  so  that  in 
4  or  5  days  the  child  is  fed  as  usual. 

Bottle-fed  infants  should  be  deprived  of  all  milk  for  several  days  and  barley 
or  rice  water,  artificial  malted  foods,  beef  or  chicken  bouillon  substituted. 
When  milk  is  allowed  again  it  should  be  boiled,  the  quantity  should  be  small 
and  the  dilution  very  weak. 

During  convalescence  the  child  should  be  carefully  watched  and  if  possible 
a  change  of  climate  is  advantageous.  The  climate  does  not  seem  to  matter 
particularly,  so  long  as  excessively  hot  neighborhoods  are  avoided;  babies  taken 
from  the  city  to  the  country  do  well  and  vice  versa.  All  errors  in  diet  should 
be  studiously  guarded  against. 

Cholera  Infantum. 

Definition.  An  acute  catarrhal  inflammation  of  the  intestinal  tract  of 
very  severe  type  characterized  by  high  temperature,  profuse  diarrhoea  and 
great  prostration. 

iEtiology.  No  specific  cause  for  this  disease  has  been  isolated  but  it  seems 
to  be  closely  associated  with  the  decomposition  of  the  intestinal  contents, 
especially  if  this  is  impure  milk.  The  predisposing  causes  are  poor  general 
condition,  unhealthy  surroundings,  etc.;  they  are  similar  to  those  of  acute 
gastro-enteritis. 

Pathology.  Post  mortem  examination  reveals  no  marked  abnormality 
in  the  aSected  intestine. 

Symptoms.  Cholera  infantum  usually  occurs  in  children  in  whom  there 
has  been  previous  intestinal  disturbance.  Prostration  and  fever  are  often 
present  before  the  appearance  of  the  vomiting  and  diarrhoea.  The  former 
may  appear  first  or  both  it  and  the  purging  may  occur  simultaneously.  The 
emesis  is  frequent,  the  vomitus  at  first  consisting  of  the  contents  of  the 


CHOLERA    INFANTUM.  405 

Stomach,  then  of  mucus,  serous  fluid  and  later  bile.  It  is  brought  on  by 
the  ingestion  of  any  food  or  drink.  The  patient  is  very  thirsty  and  eagerly 
drinks  water  only  to  vomit  it  almost  immediately.  The  movements  from 
the  bowels  are  copious,  greenish,  yellowish  or  brownish  and  may  be  as  many 
as  20  or  30  in  24  hours.  Their  odor  is,  as  a  rule,  not  foul  but  at  times  is 
offensive,  and  as  the  disease  progresses  they  become  serous. 

Nervous  symptoms  are  frequent;  at  first  they  are  those  of  excitation  of  the 
nervous  system,  later  they  may  merge  into  convulsions,  stupor  or  coma.  The 
prostration  is  marked  and  emaciation  is  rapid.  The  temperature  varies  with 
the  severity  of  the  attack  from  102°  to  105°  F.  (38.9°  to  40.5°  C),  the  pulse 
and  respiration  are  rapid  and  weak  and  at  times  irregular.  In  the  fatal  instances 
the  skin  is  cold  and  clammy  and  the  facies  typical,  the  eyes  being  sunken, 
the  skin  pale  and  the  expression  anxious  to  a  marked  degree.  The  cerebral 
symptoms  may  lead  to  a  mistaken  diagnosis  of  brain  lesion,  but  they  are 
probably  the  result  of  the  action  upon  the  nervous  system  of  toxins  absorbed 
from  the  intestine. 

In  patients  in  whom  recovery  takes  place  the  emesis  and  purging  become  less 
frequent,  the  constitutional  symptoms  become  ameliorated,  the  temperature 
falls  and  the  nervous  symptoms  subside.  Convalescence  is  slow  and  relapses 
are  very  likely  to  occur. 

The  prognosis  is  serious,  the  outcome  in  many  instances  being  fatal. 

Treatment  can  hardly  be  considered  satisfactory.  The  first  indication  is 
to  relieve  the  digestive  tract  of  its  toxic  contents.  This  is  to  be  done  by  means 
of  gastric  lavage  and  colonic  irrigation  as  described  in  the  section  on  chronic 
catarrhal  enteritis  (p.  403);  the  action  of  purgatives  is  too  delayed.  Drugs 
by  mouth  are  vomited,  consequently  hypodermatic  medication  must  be  under- 
taken. For  the  nervous  manifestations  morphine,  gr.  -^-^  to  ywu  (0.0012- 
0.0006)  with  atropine,  gr.  -^^  (0.00013)  may  be  given  to  a  child  of  i  year 
of  age  and  may  be  repeated  in  an  hour  if  improvement  is  not  noted.  For 
the  pyrexia  baths  are  indicated.  They  should  be  begun  at  80°  F.  (26.1°  C.) 
and  reduced  to  70°  F.  (21.1°  C),  may  last  from  10  to  30  minutes  and  may, 
if  necessary,  be  repeated  every  hour  or  two.  When  baths,  for  any  reason,  are 
impossible,  wrapping  the  patient  in  a  wet  sheet,  or  cold  water  injections  may 
be  substituted,  and  as  an  adjunct  to  the  hydrotherapeutic  measures,  ice  com- 
presses or  an  ice  cap  should  be  appUed  to  the  head. 

To  supply  the  fluid  lost  by  emesis  and  diarrhoea  hypodermatoclysis,  given 
as  described  under  the  treatment  of  acute  gastro-enteritis,  (p.  401)  is  indicated. 
Eight  ounces  (250.0)  or  more  of  normal  saline  should  be  administered  in  this 
fashion  every  12  hours. 

There  should  be  no  attempt  to  give  food  or  medication,  except  stimulants, 
by  the  mouth.  The  patient  may  suck  bits  of  ice  and  stimulation  by  means 
of  brandy  or  iced  champagne — small  amounts  frequently  repeated — may 


4o6        DISEASES   OF   THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

be  administered  by  this  route.  If  these  are  not  retained  hypodermatic 
stimulation — brandy  or  whiskey,  camphor,  aether,  etc. — is  indicated. 

The  feeding  and  convalescence  of  patients  suffering  from  cholera  infantum 
are  to  be  managed  according  to  the  principles  laid  down  under  the  treatment 
of  acute  gastro-enteritis  (p.  404). 

Much  can  be  done  with  regard  to  the  prophylaxis  of  this  disease  by  means 
of  attention  to  the  suggestions  on  p.  403. 

Acute  Entero-colitis. 

Synonyms.     Acute  Ileo-colitis;  Follicular  Enteritis;  Dysentery. 

Definition.  An  acute  inflammation  of  the  mucous  membranes  of  the  ileum 
and  colon  chiefly  involving  the  lymph  follicles  of  these  structures. 

.Etiology.  This  disease  is  most  frequently  seen  during  the  summer.  The 
predisposing  causes  are  the  same  as  those  of  acute  gastro-enteritis.  The 
children  affected  are  usually  under  2  years,  although  the  condition  may  occur 
up  to  the  5th  year.  Recent  research  seems  to  have  established  a  definite 
connection  between  Shiga's  bacillus  and  this  affection,  this  organism  being 
demonstrable  in  the  stools,  and  characteristic  agglutinative  blood  reactions 
being  obtainable  in  a  large  majority  of  patients. 

Pathology.  The  colon  is  the  chief  seat  of  the  lesions  and  when  the  ileum 
is  involved  these  extend  to  a  distance  of  but  2  or  3  feet  above  the  ileo-coecal 
valve.  The  mucous  membrane  is  congested  and  swollen  and  the  solitary 
and  agminated  follicles  are  enlarged.  The  follicles  of  the  large  intestine 
may  go  on  to  ulceration  but  the  agminated  follicles  of  the  ileum  rarely  are 
subject  to  this  process.  The  ulcers  may  penetrate  to  the  muscularis,  the 
wall  of  the  intestine  may  become  infiltrated  with  small  cells  and  its  thickness 
may  be  increased  to  two  or  three  times  the  normal.  There  may  be  small 
hasmorrhagic  spots  and  the  formation  of  a  false  membrane  may  occur.  The 
mesenteric  lymph  nodes  are  frequently  enlarged. 

Symptoms.  Ileo-colitis  may  have  its  origin  in  an  attack  of  cholera  infantum 
or  acute  gastro-enteritis  or  it  may  occur  as  a  primary  infection.  At  the  onset 
the  symptoms  often  resemble  those  of  acute  indigestion,  viz.,  vomiting,  abdom- 
inal pain  and  distention,  a  rise  in  temperature  and  diarrhoea;  the  stools  at  first 
are  loose  and  yellowish  or  greenish,  later  they  contain  mucus  and  blood,  are 
very  frequent  and  may  be  accompanied  by  pain.  The  mucus  may  be  clear 
or  mixed  with  faecal  matter.  After  a  week  or  thereabouts  the  symptoms  may 
disappear  and  the  patient  slowly  recover,  or  they  may  become  more  severe, 
with  persistent  fever,  frequent  stools  of  mucus  and  blood,  pain  and 
tenesmus,  loss  of  appetite  and  increasing  prostration  and  loss  of  weight. 
Nervous  symptoms,  dry,  brown  and  ulcerated  tongue  and  diminished  urine, 
at  times  containing  albumin  and  casts,  are  features  of  the  severe  infections. 


ACUTE    ENTERO-COLITIS.  407 

Such  patients  may  go  on  in  this  manner  for  4  or  5  weeks  and  die,  or  convales- 
cence, which  is  always  very  slow  and  likely  to  be  interrupted  by  relapses,  may 
become  established.  Few  of  these  patients  recover  completely,  their  powers 
of  resistance  being  so  deteriorated  that  they  are  subject  to  any  intercurrent 
disease  and  they,  as  a  rule,  finally  succumb. 

Treatment.  Prophylaxis  consists  in  early  and  careful  treatment  of  all 
intestinal  disorders  and  the  employment  of  the  measures  suggested  under 
acute  gastro-enteritis  (p.  403). 

The  treatment  of  the  attack  consists  in  emptying  the  gastro-intestinal  tract 
by  means  of  systematic  gastric  and  colonic  lavage  and  the  exhibition  of  cath- 
artics as  laid  down  on  p.  403 ;  the  pain  and  restlessness  should  be  controlled 
by  paregoric  or  the  deodorized  tincture  of  opium.  Local  treatment  of  the 
diseased  areas  in  the  intestine  by  means  of  intestinal  irrigations  of  normal 
saline  solution  is  important.  A  quart  or  two  (1000.0-2000.0)  of  the  solution 
at  a  temperature  of  about  102°  F.  (38.9°  C.)  being  allowed  to  flow  into  the 
bowel  and  out  again  through  a  soft  catheter  passed  as  high  as  possible,  two 
or  three  times  a  day.  If  there  is  much  blood  in  the  stools  small  injections  of 
hot  water — io8°-ii2°  F.  (42. 3^-44. 4°  C.) — or  of  ice  water  are  useful  and  injec- 
tions of  astringents — a  drachm  (4.0)  of  tannic  acid  to  the  pint  (500.0)  of  warm 
water — may  be  employed.  If  the  injections  cause  the  child  to  struggle  they 
must  be  omitted.  In  such  instances,  and  others  which  do  not  respond  to  the 
injections,  bismuth  subnitrate  in  considerable  doses — 20  grains  (1.33)  or 
more  every  3  or  4  hours  to  a  child  of  i  year — or  castor  oil  in  emulsion — 10 
minims  (0.66) — at  the  same  intervals  may  be  administered. 

In  the  later  stages  good  results  may  attend  the  use  of  gelatin  which  may  be 
employed  as  follows:  2^  drachms  (10. o)  of  a  10  percent,  aqueous  sterilized 
gelatin  solution  should  be  warmed  and  added  to  the  child's  bottle.  This 
dosage  should  be  given  three  times  on  the  first  day  of  its  employment — the 
amount  of  gelatin  taken  by  the  child  being  45  grains  (3.0)  per  day — and 
increased  15  grains  (i.o)  daily.  It  is  said  that  this  treatment  quickly  lessens 
the  number  of  the  stools,  supposedly  by  mechanical  action. 

Attempts  at  serum  treatment  have  been  made  but  decision  as  to  the  benefit 
to  be  derived  must  be  reserved  at  present. 

Stimulation  is  usually  necessary.  Well  diluted  brandy  is  to  be  preferred 
with  iced  champagne  as  a  second  choice;  of  either  half  a  drachm  (2.0), 
or  more  if  necessary,  may  be  given  a  child  of  i  year  every  2  or  3  hours.  In 
instances  of  profound  shock  atropine  sulphate  hypodermatically,  beginning 
in  doses  of  -^^-^  of  a  grain  (0.00013),  pushed  to  the  limit  and  followed  by 
brucine  has  been  recommended. 

It  must  be  remembered  that  too  much  medication  is  usually  much  worse  than 
too  httle,  in  fact,  when  the  acute  symptoms  have  disappeared  and  the  tempera- 
ture is  but  little  above  normal  and  the  movements  are  less  than  6  a  day,  patients 


4o8         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

frequently  do  better  when  all  drugs  are  stopped — save  stimulants — and  the 
bowel  is  irrigated  only  every  second  or  third  day.  For  such  patients  a  change 
of  air  will  often  effect  wonders. 

The  diet  during  the  acuity  of  the  attack  is  identical  with  that  described  for 
instnces  of  acute  gastro-enteritis.  After  the  acute  stage  is  over,  great  difficulties 
are  often  experienced  and  the  most  judicious  feeding  is  necessary.  Each  patient 
must  be  studied  by  himself  and  no  fixed  rules  can  be  laid  down.  To  infants, 
foods  which  may  be  given  are  peptonized  skim  milk,  broths,  beef  peptonoids, 
barley  or  rice  water  and  the  various  artificial  malted  foods.  Feeding  by 
gavage  may  be  necessary  in  instances  of  disinclination  to  eat.  Food  should  not 
be  given  oftener  than  every  2  or  3  hours,  but  drinking  water  may  be  allowed 
in  the  intervals. 

For  older  children  during  convalescence,  scraped  beef,  kumyss,  gruels,  and 
soft  boiled  eggs  are  allowable.  The  greatest  attention  should  be  given  the 
diet  for  a  long  period  after  an  attack  since  the  slightest  indiscretion  may 
result  in  a  recurrence  of  the  disease. 

Hygienic  treatment  should  be  carried  out  as  described  under  the  treatment 
of  acute  gastro-enteritis  (p.  403). 

PSEUDO-MEMBRANOUS  ENTERO-COLITIS. 

Synonyms.     Croupous  Entero-colitis;  Diphtheritic  Entero-colitis. 

Definition.  An  acute  inflammation  of  the  lining  of  the  intestine  accom- 
panied by  the  formation  of  a  false  membrane. 

.etiology.  This  disease  is  probably  the  result  of  the  irritant  action  of 
chemical  substances  resulting  from  intestinal  fermentation  or  of  infection  by 
bacteria.  The  former  astiological  factor  may  act  in  poisoning  by  mineral 
substances,  such  as  arsenic,  mercury  or  lead.  The  condition  may  also  be 
secondary  to  various  of  the  infectious  diseases  such  as  pyaemia,  scarlatina, 
smallpox,  etc.  Whether  here  the  intestinal  lesion  arises  directly  from  infection 
by  the  specific  organism  causing  the  disease  or  not  is  uncertain.  Diphtheritic 
enteritis  also  occurs  as  a  complication  in  cachectic  states,  nephritis,  hepatic 
cirrhosis,  etc. 

Pathology.  Usually  only  the  large  intestine  is  affected  but  in  the  instances 
due  to  mineral  poisons  the  small  intestine  may  also  be  involved.  Early  in  the 
disease  the  lesions  are  usually  those  of  simple  intestinal  catarrh,  but  more 
infrequently  the  membrane  is  present  from  the  inception  of  the  inflammation. 
The  membrane  varies  in  size  and  thickness  and  is  grayish  white  in  color. 
Ulceration  may  be  present  with  necrosis  and  perforation  or  increase  in  thick- 
ness of  the  intestinal  wall. 

Symptoms.  These  are  not  characteristic  and  in  mild  instances  they  may  be 
unnoticed.     Severe  instances  resemble  dysentery  (q.v.) ;  the  stools  are  frequent, 


PHLEGMONOUS    ENTERITIS.  409 

thin  and  accompanied  by  tenesmus;  they  may  contain  blood,  pus  and  bits 
of  the  membrane.  The  course  of  the  disease  is  greatly  influenced  by  its 
causation,  but  it  is  usually  slow.  The  prognosis  is  not  good,  death  occurring 
from  exhaustion,  peritonitis  or  haemorrhage.  Patients  who  recover  are  often 
left  with  permanent  intestinal  stenoses  due  to  the  contraction  of  the  intestinal 
cicatrices. 

Treatment  consists  in  the  proper  management  of  the  co-existent  and  causative 
affection  and  in  the  relief  of  the  symptoms  as  they  arise.  For  details  the 
reader  is  referred  to  the  sections  on  the  treatment  of  intestinal  ulceration  and 
colitis. 

PHLEGMONOUS  ENTERITIS. 

This  is  a  rare  affection.  It  is  probably  of  infective  origin  and  consists  in 
an  infiltration  by  pus  of  the  intestinal  wall.  It  may  foUow  other  intestinal 
inflammations  such  as  ulceration  and  has  occurred  in  strangulated  hernia 
and  intussusception.  Little  is  definitely  known  about  the  disease  and  diag- 
nosis ante  mortem  is  considered  impossible. 

HiEMORRHAGIC  INFARCT  OF  THE  BOWEL. 

Definition.  An  extravasation  of  blood  into  the  intestinal  wall  resulting 
from  thrombosis  or  embolism  of  one  of  the  mesenteric  arteries  or  one  of  their 
branches. 

.Etiology.  The  causes  of  intestinal  embolism  are  identical  with  those  of 
embolism  of  any  other  part,  namely  valvular  heart  disease,  aneurysm,  etc. 

Pathology.  The  walls  of  the  jejunum  and  ileum  are  congested  and  swollen 
and  a  clot  obstructing  either  the  superior  or  inferior  (usually  the  former)  mes- 
enteric artery  or  one  of  their  branches  is  demonstrable. 

Congestion  and  infiltration  may  also  be  observed  in  the  mesentery. 

Symptoms.  Of  these  the  most  important  is  haemorrhage  from  the  bowel. 
The  onset  of  the  affection  is  usually  marked  by  sudden  nausea  followed  by 
vomiting,  colicky  pain  and  abdominal  distention.  The  bowels  are  loose 
and  the  movements  may  contain  blood  from  the  beginning  or  not  until  later. 
Instances  in  which  the  symptoms  closely  resemble  those  of  obstruction  are 
more  rare.  The  prognosis  is  bad  although  recovery  is  possible  through  the 
establishment  of  a  collateral  circulation. 

Treatment  is  unsatisfactory  it  being  limited  to  the  relief  of  the  symptoms 
and  the  diminution  of  the  excessive  blood  pressure  in  the  portal  circulation 
by  means  of  cardiac  stimulation  and  venesection. 

Surgical  interference — resection  followed  by  enterostomy — has  been  suc- 
cessful in  a  few  instances. 


41 0         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

ULCERATION  OF  THE  BOWEL. 
Ulcer  of  the  Duodenum. 

Etiology.  Duodenal  ulcer  probably  occurs  more  often  than  is  generally 
supposed  and  is  produced  by  the  same  causes  as  those  which  result  in  gastric 
ulcer,  with  which  it  may  be  associated.  Its  chief  aetiological  factors  are  trau- 
matism resulting  from  foreign  bodies,  excessive  gastric  acidity,  local  infection, 
embolism  or  thrombosis  in  the  duodenal  wall,  with  consequent  tissue  necrosis, 
and  severe  skin  affections  such  as  burns,  erysipelas,  etc.  Ulcer  of  the  duod- 
enum, however,  is  much  less  frequent  than  gastric  ulcer. 

Pathology.  The  morbid  anatomy  is  similar  to  that  of  gastric  ulcer  (q.v.) 
in  every  way  both  in  gross  appearance  and  under  the  microscope.  The 
lesion  may  be  single  or  multiple  and  is  usually  in  the  first  portion  of  the  duod- 
enum. Perforation  takes  place  more  frequently  than  in  gastric  ulcer  and 
general  or  localized  peritonitis  walled  off  by  adhesions,  results.  When  the 
adhesions  involve  the  neighboring  organs  perforation  into  these  may 
occur. 

Symptoms.  These  are  so  little  characteristic  as  to  render  diagnosis  very 
difficult  and  often  when  they  are  sufl&ciently  marked  to  raise  suspicion  they  are 
so  analogous  to  those  of  ulcer  of  the  stomach  that  differentiation  from  the  latter 
lesion  may  be  well-nigh  out  of  the  question.  The  most  important  symptoms 
are  pain  and  haemorrhage.  The  former,  however,  may  be  absent  or  so  insig- 
nificant as  to  attract  little  notice  from  the  patient;  it  is  usually  less  severe  than 
that  of  gastric  ulcer  and  is  likely  to  appear  at  a  longer  interval  after  eating, 
though  this  latter  statement  is  doubted  by  some  authorities.  Haemorrhage 
is  not  rare,  and  varies  from  a  quantity  so  slight  as  to  be  hardly  noticed  to  a 
considerable  amount  which  is  either  vomited,  leaves  the  body  through  the 
intestine  or  is  carried  off  by  both  these  routes.  The  vomited  blood  is  similar 
to  that  of  gastric  ulcer,  while  that  passed  in  the  stools  is  black  and  tarry. 

Jaundice  may  occur,  but  is  so  infrequent  as  to  cause  doubt  on  the  part  of 
some  observers  as  to  whether  it  is  a  part  of  the  clinical  picture  or  merely  a 
coincidence. 

Vomiting  is  not  a  common  symptom;  it  may  appear  as  a  result  of  a  co-exis- 
tent gastric  inflammation  or  be  due  to  duodenal  obstruction  resulting  from 
the  cicatricial  contraction  of  an  old  ulcer.  The  vomitus  and  the  stomach 
contents  in  duodenal  ulcer  are  not  typical  in  any  way. 

The  appetite  is  often  excellent;  the  bowels  are  usually  constipated  but  may 
be  entirely  normal  in  their  action. 

Perforation  induces  the  usual  symptoms  of  intestinal  rupture,  either  those 
of  general  or  localized  peritonitis. 

The  prognosis  is  not  good  as  regards  recovery.  In  non-perforative  instances 
the  symptoms  may  continue  for  years  despite  treatment  and  in  perforative  in- 


PRIMARY   TUBERCULOUS    ULCERATION   OF   THE    INTESTINE.       411 

Stances,  without  adhesions  to  wall  off  the  general  abdominal  cavity,  death  is 
certain,  unless  immediate  operation  is  undertaken. 

Treatment  is  practically  that  of  gastric  ulcer  (p.  361)  as  regards  both 
medical  and  surgical  measures,  ^ 

Primary  Tuberculous  Ulceration  of  the  Intestine. 

This  is  a  rare  condition  and  one  seldom  seen  in  the  absence  of  tuberculous 
lesions  in  other  parts  of  the  body,  still  it  may  occur  under  these  circumstances. 
The  condition  is  seen,  as  a  rule,  in  children.  The  ulcers  are  situated  in 
the  small  intestine  and  the  rectum,  seldom  in  the  colon.  They  begin  in  the 
agminated  follicles  as  tubercles  which  undergo  caseation  and  finally  ulcer 
formation.  The  ulcers  are  irregularly  oval,  their  longer  diameter  is  parallel  to 
the  transverse  axis  of  the  intestine,  their  edges  are  undermined  and  there  is 
thickening  of  the  peritonaeal  coat.  Unless  in  the  rectum  where  they  may  be  seen 
by  means  of  the  proctoscope  their  existence  cannot  be  certainly  diagnosed 
intra  vitam.     Rarely  they  may  be  found  in  the  appendix  vermiformis. 

Symptoms  which  lead  one  to  suspect  the  existence  of  such  lesions  are  diar- 
rhoeal  discharges  with  pus  and  with  or  without  blood,  loss  of  flesh  and  strength, 
hectic  temperature,  abdominal  tenderness,  and  enlarged  peritonaeal  glands. 

The  faecal  discharges  should  be  examined  for  the  tubercle  bacillus,  which 
if  found,  when  it  is  certain  that  it  has  not  been  swallowed,  establishes 
the  diagnosis.  Inability  to  demonstrate  the  bacillus  is  no  proof  that  the 
lesion  is  not  tuberculous. 

Perforation  of  a  tuberculous  ulcer  rarely  takes  place;  when,  however, 
this  event  happens  general  or  localized  peritonitis  with  its  attendant  symptoms 
results.     Healed  ulcers  cicatrize  and  may,  by  their  contraction,  cause  stenosis. 

Treatment  consists  in  the  employment  of  the  means  calculated  to  relieve 
the  diarrhoea,  the  pain  (see  p.  364)  and  the  haemorrhage  (see  p.  365).  Local 
treatment  of  the  ulcers  is  possible  when  they  exist  in  the  rectum,  and  the 
lower  colon;  here  irrigations,  after  the  bowel  has  been  cleansed  by  an  enema 
of  warm  water,  with  solutions  of  copper  or  zinc  sulphate  (3  to  1,000),  silver 
nitrate  (1-2  to  1,000),  silver  vitellin  (5  percent.),  tannic  (2-4  to  1,000),  or 
boric  acid  (1-2  to  100)  are  useful.  Ulcers  which  can  be  reached  by  means 
of  the  speculum  and  applicator  should  be  touched  with  stick  silver  nitrate 
or  with  strong  solutions  of  the  same  salt. 

Internally  the  bismuth  salts  may  be  given  as  suggested  under  the  treatment 
of  chronic  intestinal  catarrh  (p.  397). 

The  administration  of  a  combination  of  sulphur  sublimatum,  gr.  xx  (1.33) 
and  pulvis  ipecacuanhae  et  opii,  gr.  v  (0.33)  every  4  hours  has  been  recom- 
mended in  tuberculous  intestinal  ulceration  in  adults. 

The  diet  should  be  carefully  regulated,  consist  entirely  of  non-irritating 


412         DISEASES    OF    THE    DIGESTIVE    SYSTEM    ANP    PERITONEUM. 

foods  and  should  contain  as  much  nourishment  as  possible.  For  more  specific 
directions  for  the  feeding  of  these  patients  the  reader  is  referred  to  the  section 
on  the  diet  of  chronic  catarrhal  enteritis  (p.  399). 

Embolic  Ulcer  of  the  Intestine. 

This  affection  is  uncommon  and,  like  other  forms  of  intestinal  ulceration, 
very  difl&cult  of  diagnosis.  The  ulcers  occur  in  valvular  endocarditis,  arterio- 
sclerosis, multiple  neuritis,  pyaemic  conditions,  and  any  other  state  in  which 
lodgment  of  an  embolus  in  an  artery  of  the  intestine  is  possible.  Following 
the  lodgment  of  the  embolus  necrosis  of  tissue  and  ulceration  take  place. 

Syphilitic  Ulcer  of  the  Intestine. 

This  is  a  rare  condition  especially  in  the  small  intestine;  syphilitic  ulcers 
of  the  rectum  are  more  frequently  seen  and  are  usually  situated  within  a 
short  distance  of  the  anus.  They  are  shallow,  of  smooth  base  and  may 
occur  as  primary,  secondary  or  tertiary  lesions;  in  the  last  case  they  result 
from  the  breaking  down  of  gummata.  In  healing  they  tend  to  produce  stric- 
tures though  certain  recent  observers  incline  to  the  belief  that  this  latter  is  a 
very  rare  occurrence. 

The  treatment  consists  in  the  administration  of  mercury  and  the  iodides 
as  described  under  the  section  devoted  to  luetic  disease  (p.  151),  and  when  the 
lesions  are  in  proper  situation,  local  applications  such  as  those  suggested  in  the 
treatment  of  tuberculous  ulceration  may  be  employed. 

APPENDICITIS. 

Definition.  An  acute  or  subacute  catarrhal  or  suppurative  inflammation 
affecting  the  appendix  vermiformis,  usually  involving  the  surrounding 
tissues  (typhlitis  and  peri-typhlitis)  and  frequently  going  on  to  gangrene  or 
perforation  of  the  organ  with  consequent  abscess  formation. 

iEtiology.  While  it  is  probable  that  this  affection  occurred  as  frequently 
before  1886,  the  date  of  the  classical  paper  of  Fitz  of  Boston,  as  it  has  done 
since  that  time,  previous  to  that  year  the  importance  of  the  disease  was  not 
generally  recognized. 

Appendicitis  is  a  disease  of  young  adult  life  occurring  most  frequently 
between  the  ages  of  15  and  30  years;  it  is  rare  in  children  and  after  the  age  of 
50.  Males  are  more  often  affected  than  females,  perhaps  because  they  are 
more  prone  to  muscular  exertion  or  more  probably  because  in  the  weaker  sex 
the  organ  receives  an  additional  blood  supply  from  a  branch  of  the  right 
ovarian  artery. 


APPENDICITIS.  413 

The  anatomical  formation  of  the  appendix  greatly  favors  its  liability  to 
inflammation.  It  is  a  blind  sac  narrower  at  its  orifice  than  elsewhere,  conse- 
quently any  inflammation  of  its  cavity  increases  the  narrowness  of  the  outlet, 
thus  preventing  free  drainage  and  exit  of  the  offending  cause  of  the  process 
and  favoring  its  further  development.  The  shortness  of  its  mesentery  is  another 
anatomical  factor  in  the  liability  of  the  appendix  to  infection.  This  shortness 
of  mesentery  is  likely  to  cause  a  torsion  of  the  organ,  which  may  shut  off  its 
blood  supply  and  interfere  with  its  nutrition,  since  the  artery  supplying  the 
part  is  carried  in  the  meso-appendix.  Long  appendices  are  particularly  subject 
to  torsion  because  of  their  proneness  to  adhere  to  other  tissues. 

The  presence  of  foreign  bodies — the  traditional  grape  seed,  etc. — is  much 
less  a  factor  in  the  causation  of  appendicitis  than  the  laity  are  accustomed 
to  suppose.  It  is  true  that  foreign  substances,  especially  faecal  concretions, 
are  not  infrequently  found  in  diseased  appendices,  but  these  must  be  con- 
sidered as  predisposing  causes  only.  Various  intestinal  parasites  have  also 
been  found  in  this  situation. 

Errors  in  diet,  exposure  to  cold,  excessive  muscular  exertion  and  trauma- 
tism are  also  factors  in  the  production  of  this  inflammation. 

The  exciting  cause  of  appendicitis  is  a  bacterial  infection.  Of  the  micro- 
organisms to  be  considered  in  this  connection  the  most  important  and  the 
one  most  frequently  responsible  is  the  bacillus  coli  communis.  This  bacterium 
is  a  normal  inhabitant  of  the  intestinal  tract  and  as  such  is  harmless — even 
beneficial — but,  confined  in  an  appendix,  in  some  manner  it  becomes  malig- 
nant. Not  only  is  this  bacillus  capable  of  exciting  appendiceal  inflammation 
but  others,  such  as  the  streptococcus  and  staphylococcus  pyogenes,  the  pneu- 
mococcus,  the  bacilli  of  influenza  and  enteric  fever,  the  bacillus  proteus  and 
the  infective  cause  of  acute  rheumatism,  having  found  ingress  to  the  appendix, ' 
are  potent  in  this  regard. 

Pathology.  For  purposes  of  ease  in  description  appendicitis  may  be 
separated  from  a  pathological  standpoint  into  four  types,  a.  Catarrhal,  b. 
Obliterative,   c.  Ulcerative,   d.  Gangrenous. 

In  the  catarrhal  type  the  mucous  lining  of  the  organ  is  congested  and  swollen, 
there  is  excessive  production  of  mucus,  with  which  are  mixed  leucocytes  and 
desquamated  epithelial  cells,  which  distends  the  cavity  of  the  appendix  and 
the  free  exit  of  which  is  prevented  by  the  swelling  of  the  normally  narrow 
opening  of  the  organ.  Such  an  inflammation  predisposes  to  other  like  attacks 
and  also  lessens  the  resistance  of  the  appendiceal  tissues  so  that  they  become 
susceptible  to  infection  by  pathogenic  micro-organisms. 

Obliterative  appendicitis  is  really  but  a  later  stage  of  the  preceding  type, 
especially  of  its  severer  forms,  where  the  submucosa,  as  well  as  the  mucosa, 
is  involved.  Here  there  is  thickening  of  the  wall  of  the  organ  by  means  of  cell 
infiltration,  and  a  consequent  decrease  in  and  at  times  an  obliteration  of 


414         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

the  lumen  of  the  tube.  Ulcers  also  may  occur  which  by  contraction  or  by 
adherence  of  their  surfaces  further  tend  to  contract  the  calibre  of  the  organ. 
Of  this  form  of  the  inflammation  three  courses  may  be  described:  First,  the 
organ  may  be  entirely  obliterated  and  converted  into  fibrous  tissue,  therewith 
precluding  all  possibility  of  further  attacks  of  appendicitis;  secondly,  when 
mucus  or  purulent  fluid  is  retained  in  the  cavity  of  the  organ  behind  a  stenosis 
the  patient  is  subject  to  appendiceal  crises;  and  thirdly,  when  the  inflammation 
has  been  marked  enough  in  character  to  involve  the  peritonaeal  coat,  adhesions 
to  other  structures  with  consequent  inflammation  of  the  same  by  extension 
of  the  infection  may  be  formed. 

In  the  ulcerative  type  of  the  affection  the  mucosa  and  submucosa  are  necrosed 
in  varying  degrees.  The  presence  of  foreign  bodies  or  faecal  concretions  is 
especiaUy  likely  to  produce  lesions  of  this  form,  it  is  also  seen  as  a  result  of 
the  two  types  described  above,  and  it  may  occur  in  enteric  fever  and  tubercu- 
losis. The  ulceration  may  result  in  perforation  and  general  or  localized 
peritonaeal  inflammation. 

In  the  gangrenous  type  rapid  sloughing  takes  place  of  either  the  entire 
organ  or  portions  of  its  wall;  in  either  case  the  condition  is  a  very  grave  one 
on  account  of  its  liability  to  occur  with  little  or  no  warning  and  even  without 
history  of  previous  attacks  of  the  milder  forms  of  appendiceal  inflammation. 
The  process  may  result  in  general  peritonitis  of  the  severest  type  or  the  resist- 
ing power  of  the  patient  may  be  such  as  to  permit  of  the  walling  off  of  the 
sloughing  part  and  the  limitation  by  adhesions  of  the  process  to  a  localized 
abscess  cavity. 

The  localized  peritonaeal  inflammations  occurring  with  the  appendiceal 
lesions  described  above  vary  in  degree  from  a  simple  peri-appendicular  plastic 
exudate  forming  adhesions  to  the  adjacent  tissues  which  limit  the  spread  of  the 
infection,  to  severer  forms  with  a  cavity  containing  purulent  exudate  and 
walled  off  by  adhesions  from  the  general  peritonaeal  cavity.  Such  an  abscess 
cavity  usually  occupies  the  right  iliac  fossa  although  it  may  be  found  in  any 
part  of  the  abdominal  cavity — in  the  pelvis,  the  lumbar  region,  under  the  liver, 
etc. — owing  to  unusual  situations  of  the  appendix.  These  abscesses  contain 
from  a  few  drachms  to  a  pint  or  more  of  thick  or  thin,  odorless  or  foul  pus. 
The  suppurative  process  may  break  its  adhesions  and  discharge  into  the 
peritonaeal  cavity,  resulting  in  general  peritonaeal  infection,  or  into  the  intes- 
tine, the  bladder  or  vagina.  Rupture  may  also  take  place  outward  through 
the  abdominal  wall.  Metastatic  abscesses  in  the  liver  may  be  set  up  through 
portal  embolism  or  pylephlebitis. 

Symptoms.  Mild  catarrhal  inflammations  of  the  appendix  are  likely  to 
cause  but  sUght,  often  hardly  noticeable,  symptoms;  of  these  pain  in  the  right 
iliac  fossa  and  slight  tenderness  are  the  only  ones  worthy  of  mention;  indeed 
the  process  may  proceed  to  the  ulcerative  stage  without  exciting  any  appre- 


APPENDICITIS.  415 

hension  on  the  part  of  the  patient.  When  the  inflammation  has  involved 
the  peritonaeum  locally  the  symptoms  usually  become  marked.  There  is 
pain,  at  first  general,  but  after  a  few  hours  localized  over  the  seat  of  the  lesion 
in  the  right  iliac  fossa  w^hen  the  appendix  is  normally  situated,  but  the  tendency 
of  this  organ  to  be  in  anomalous  situations  may  result  in  localized  pain  in  any 
part  of  the  abdominal  cavity — under  the  liver,  in  the  left  iliac  fossa,  etc.  Change 
of  position  increases  the  pain,  as  does  deep  inspiration  or  coughing. 

The  tongue  is  likely  to  be  dry  and  coated.  Vomiting  is  often  present  but 
the  vomitus  is  not  characteristic  in  any  way.  The  bowels  are  usually  con- 
stipated this  being  due  to  paralysis  of  the  intestinal  musculature.  At  times 
this  symptom  is  so  marked  as  to  suggest  obstruction  and  it  may  be  accom- 
panied by  faecal  vomiting.     More  rarely  the  bowels  are  loose. 

The  temperature  is  usually  elevated,  ioi°-io3°  F.  (38.5°-39.4°  C),  at  first, 
gradually  falling  as  the  process  goes  on  to  resolution,  or  assuming  the  charac- 
teristic irregularity  if  pus  is  present,  although  rarely  such  instances  may  occur 
without  pyrexia.  The  pulse  is  full  and  rapid — 100  to  120.  Abdominal  dis- 
tention may  be  present  and  is  most  marked  in  perforative  instances.  A  leuco- 
cytosis  of  20,000  to  30,000  is  not  unusual. 

Physical  Examination.  The  patient  usually  lies  on  his  back  with  the 
right  thigh  flexed  on  the  pelvis,  this  position  offering  some  relief  to  the  pain. 
Upon  palpation  a  point  of  more  or  less  localized  tenderness  will  be  found. 
The  classical  situation  for  the  point  of  maximum  tenderness  is  at  the  middle 
point  of  a  line  drawn  from  the  right  anterior  superior  iliac  spine  to  the  umbil- 
icus, although  in  anomalously  situated  appendices  it  will  be  found  over  the 
site  of  the  inflammation.  An  important  diagnostic  sign  is  rigidity  of  the 
abdominal  mu3cles  of  the  right  side,  these  structures  going  on  guard  imme- 
diately when  any  attempt  at  palpation  is  made. 

After  the  tissues  have  been  matted  together  by  plastic  adhesions  or  when 
abscess  formation  has  taken  place  a  tumor  of  varying  size  and  consistency 
may  be  palpable.  Observers  with  a  highly  specialized  sense  of  touch  may 
at  times  be  able  to  feel  the  enlarged  and  inflamed  appendix. 

Over  the  tumor,  when  such  exists,  the  percussion  note  is  dull  and  in  the 
presence  of  a  considerable  quantity  of  pus  may  be  flat.  Excessive  distention 
of  the  intestine  by  gas  gives  a  note  more  tympanitic  than  normal. 

The  prognosis  for  recovery  in  attacks  of  the  simple  catarrhal  type  is  good 
but  recurrences  are  frequent.  In  the  instances  with  perforation  and  abscess 
formation  the  outlook  is  much  less  favorable,  especially  where  surgical  inter- 
vention is  postponed. 

Treatment.  Probably  there  is  no  point  in  medicine  or  surgery  upon  which 
authorities  are  so  prone  to  disagreement  as  upon  the  proper  management  of  this 
disease.  While  early  surgical  intervention  in  every  instance  has  its  advocates 
and  these  of  such  character  as  to  demand  consideration,  it  is  the  part  of  con- 


41 6         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

servatism  to  treat  an  attack  of  catarrhal  appendicitis  by  medical  means  and  to 
consider  the  advisability  after  recovery,  of  the  so-called  interval  operation. 
Every  patient  suffering  from  catarrhal  appendicitis  should  be  kept  at  absolute 
rest  in  bed.  For  the  relief  of  the  pain  the  question  of  the  advisability  of  the 
administration  of  opium  is  a  debatable  one.  While  this  drug  puts  the  intestine 
at  rest,  thus  favoring  resolution,  as  no  other  drug  will,  it  is  insisted  by  some 
that  its  exhibition  masks  the  symptoms  indicating  the  necessity  for  operative 
interference.  The  point  against  this  assertion  is  that  the  careful  observer 
will  receive  sufiScient  information  as  to  the  time  for  operation  from  the  pulse, 
temperature,  general  condition  of  the  patient  and  the  state  of  the  appendiceal 
tumor.  Opium  itself,  given  by  mouth  or  in  suppositories,  is  to  be  preferred 
to  morphine — the  latter,  however,  may  be  given  hypodermatically  when  the 
opium  itself  for  any  reason  cannot  be  administered  by  the  other  channels  men- 
tioned. The  tincture  of  opium  may  be  administered  in  doses  of  lo  or  12 
minims  (0.66-0.8)  every  hour  until  2  or  3  doses  have  been  taken,  then  5  minims 
(0.33)  may  be  given  every  3  hours  until  the  pain  is  relieved.  If  the  pain 
recurs  another  such  a  course  of  medication  may  be  instituted.  The  resulting 
constipation  need  cause  no  alarm  but  should  not  be  allowed  to  persist  longer 
than  a  week. 

Local  applications  to  the  painful  area,  of  the  ice  coil,  ice  bag  or  ice  compress 
are  indicated  and  will  be  found  to  greatly  relieve  the  pain  and  perhaps  retard 
the  progress  of  the  inflammation.  Warm  compresses  may  be  used  after  the 
temperature  has  fallen  to  normal  and  the  inflammatory  process  is  quiescent. 
The  use  of  blisters  and  leeches  is  unadvisable  since,  if  operation  becomes 
necessary,  the  resistance  to  infection  of  the  skin  at  their  points  of  application 
is  impaired. 

Whether  or  not  to  administer  laxatives  is  a  debatable  question.  Active 
purgatives  should  never  be  given.  There  is  no  doubt  that  oftentimes  attacks  of 
iliac  pain,  emesis  and  constipation  with  what  seems  to  be  a  tumor  in  the  appen- 
diceal region  quickly  recover  after  a  free  movement  of  the  bowels,  but  there 
is  reasonable  doubt  as  to  whether  such  are  instances  of  true  appendicitis. 
Early  in  appendicitis  the  object  is  to  keep  the  intestine  as  nearly  in  a  state  of 
complete  rest  as  possible,  consequently  here,  as  well  as  when  perforation  is 
imminent  or  after  suppuration  has  set  in,  purgation  is  contra-indicated.  Con- 
stipation may  be  allowed  to  last  5  or  7  days  and,  when  the  chances  of  perforation 
are  past,  the  bowels  may  be  moved  by  carefully  given  rectal  irrigation  and 
should  he  kept  regularly  open  thereafter. 

The  elaboration  of  an  antitoxin  from  the  colon  bacillus — since  this  organ- 
ism is  so  often  concerned  in  the  causation  of  this  disease — has  been  suggested 
with  the  idea  in  view  that  patients  may  be  immunized  against  relapses  and 
against  the  danger  of  secondary  infection  by  pus  dm-ing  operation. 

The  diet  during  the  acuity  of  the  attack  should  be  entirely  liquid,  milk. 


INTESTINAL    OBSTRUCTION.  417 

soups,  the  artificial  infant  foods,  etc.,  and  in  quantity  should  be  small;  certain 
clinicians  even  advocate  feeding  per  rectum  in  preference  to  that  by  mouth. 
Small  amounts  of  water  may  be  taken.  When  the  acuity  of  the  symptoms 
has  subsided  semi-solids  may  be  allowed  and  later,  sweetbreads,  scraped 
beef,  cereals,  etc.,  may  be  added. 

The  indication  for  surgical  intervention  is,  in  the  minds  of  many  competent 
authorities,  the  establishment  of  the  diagnosis  of  the  disease,  but  it  is  certain 
that  many  patients  recover  under  careful  medical  treatment.  Concerning  such, 
the  question  of  an  interval  operation  is  one  to  be  decided  among  the  patient, 
his  physician  and  his  surgeon.  The  most  conservative  clinicians  concur  that 
operation  is  indicated  in  all  instances  in  which  the  symptoms  do  not  ameliorate 
within  from  24  to  48  hours,  in  instances  in  which  an  abscess  has  formed  and  in 
early  instances  of  general  perforative  peritonitis.  Advanced  instances  of  diffuse 
peritonitis  which  are  in  a  state  of  practical  collapse  with  rapid  and  feeble  puse, 
clammy  and  cold  skin  are  hardly  fit  subjects  for  operation.  Here  stimulation, 
heat  to  the  extremities,  high  rectal  irrigations  of  normal  saline  solution  and 
the  other  means  usually  employed  in  such  conditions  are  indicated.  Very 
rarely  does  recovery  take  place. 

INTESTINAL  OBSTRUCTION. 

Definition.  A  condition  in  which  the  normal  passage  of  faecal  matter 
through  the  bowel  is  impeded.  This  may  result  from  mechanical  obstruction 
or  paralysis  of  the  intestinal  musculature  and  may  be  due  to  a  number  of 
different  causes. 

Intestinal  obstruction  occurs  in  two  forms: 

a.  The  acute,  which  may  be  caused  by  congenital  anomalies,  internal 
"strangulation,  volvulus,  intussusception,  foreign  bodies  or  abnormal  intestinal 
contents  and  intestinal  paralysis. 

h.  The  chronic,  which  is  the  result  of  narrowing  of  the  calibre  of  the  bowel 
from  new  growths  within  this  structure,  cicatricial  contraction,  from  the 
outside  pressure  of  tumors  of  neighboring  organs  or  structures  or  of  the 
accumulation  of  impacted  faeces. 

I.  Congenital  Anomalies. 

These  are  the  result  of  insufficient  or  improper  foetal  development  and 
may  be  situated  at  any  part  of  the  digestive  tract.  The  most  frequent  sites 
are  at  the  pylorus  (see  p.  373),  in  the  duodenum,  in  the  ileum  and  at  the 
anus.     Oftentimes  there  may  be  stenoses  at  two  or  more  of  these  situations. 

Symptoms.  In  instances  of  imperforate  anus  there  is  no  passage  of  meconium 
and  the  examining  finger  will  at  once  perceive  the  defect.  When  the  obstruc- 
27 


41 8        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

tion  is  at  other  parts  of  the  digestive  tract  the  symptoms  usually  do  not  appear 
until  food  has  been  taken.  Here  the  symptoms  are  vomiting,  at  times  ster- 
coraceous  in  character,  abdominal  pain  and  ineffectual  efforts  to  pass  faeces. 
At  times  visible  peristaltic  action  may  be  detected  upon  inspection  of  the 
abdomen.     The  prognosis  is  not  good. 

Treatment  is  wholly  surgical.  An  imperforate  anus  may  easily  be  relieved 
by  means  of  the  knife.  A  stricture  at  a  higher  level  offers  difficulties  since 
the  diagnosis  of  its  situation  is  well-nigh  impossible.  Death,  however,  being 
certain  without  operation,  this  latter  should  be  undertaken,  and  the  stenosis 
being  found,  either  a  resection  should  be  done  or  an  artificial  anus  formed. 
Either  operation  is  unsatisfactory  for  death  from  inanition  is  practically 
svu-e  to  supervene. 

2.  External  Strangulation. 

This  is  the  most  frequent  variety  of  intestinal  obstruction  and  is  caused  by 
compression  of  the  bowel  by  inflammatory  adhesions  or  bands,  foetal  remains, 
such  as  the  omphalo-mesenteric  duct,  the  slipping  of  a  knuckle  of  the  intes- 
tine into  one  of  the  peritonaeal  fossae,  through  the  foramen  of  Winslow, 
through  the  diaphragm,  etc.  The  small  intestine  is  involved  in  the  great  ma- 
jority of  instances  and  the  affection  is  most  common  in  males  in  early  adult  life. 

Symptoms.  Of  these  the  most  prominent  is  sudden,  very  severe  pain  which 
is,  as  a  rule,  constant,  but  may  be  accentuated  at  intervals.  Persistent  vomit- 
ing occurs  and  after  2  or  3  days  becomes  stercoraceous.  The  bowels  are 
constipated,  but  absolute  constipation  does  not  come  on  until  the  bowel  below 
the  obstruction  has  emptied  itself.  The  intestine  above  the  obstruction  dis- 
tended with  flatus  (Wahl's  sign)  and  may  be  demonstrated  upon  physical  ex- 
amination. The  temperature  is  at  first  unaffected,  later  it  may  rise  to  ioi°-io2° 
F.  (38.5°-38.9°  C);  the  pulse  is  rapid  and  weak.  In  the  various  forms  of  acute 
obstruction  a  useful  diagnostic  symptom  is  the  gradual  increase  in  abdominal 
girth  which  is  due  to  the  augmenting  meteorism.  This  symptom  may  be 
demonstrated  by  taking  measurements  at  intervals. 

Treatment.  This  consists  in  operation  as  soon  as  the  diagnosis  is  made. 
In  instances  in  which  consent  to  operate  is  withheld,  means  for  relieving  the 
patient's  symptoms  should  be  instituted  as  described  under  the  treatment  of 
intestinal  obstruction  in  general  (p.  422). 

3.  Volvulus. 

This  form  of  intestinal  obstruction  is  due  to  a  twisting  of  a  loop  of  the 
intestine  about  the  mesentery  as  an  axis.  It  occurs  most  often  in  men  of 
middle  age  and  is  rather  infrequent.     The  small  intestine  is  usually  involved 


INTUSSUSCEPTION.  419 

although  instances  of  volvulus  of  the  stomach  and  of  the  colon  have  been  re- 
recorded. The  torsion  of  the  gut  causing  interference  with  its  blood  supply, 
peritonitis  and  at  times  necrosis  with  rupture  may  result.  This  type  of  ob- 
struction is  not  an  infrequent  sequela  of  abdominal  operations. 

Sjrmptoms.  The  pain  of  this  form  of  obstruction  is  less  severe  than  in  any 
other  variety.  The  constipation,  however,  is  absolute  and  abdominal  dis- 
tention is  a  marked  feature.  The  vomiting  and  other  symptoms  are  similar 
to  those  of  obstruction  due  to  strangulation. 

Treatment  other  than  by  operation  will  be  dealt  with  under  the  general 
management  of  intestinal  obstruction  (p.  422). 

4.  Intussusception. 

Intestinal  intussusception  consists  in  the  telescoping  of  one  section  of  the 
bowel  into  another.  The  invagination  consists  of  the  intussuscipiens,  the 
outer  layer,  and  the  intussusceptum,  the  two  inner  layers.  The  condition 
may  be  simulated  for  purposes  of  illustration  by  slipping  one  part  of  a  glove 
finger  into  another.  The  condition  is  named  in  accordance  with  the  part  or 
parts  of  the  intestine  involved,  e.g.,  enteric  when  the  small  intestine  alone 
is  affected,  ileo-coecal  when  the  ileum  and  coecum  are  invaginated  into  the 
colon,  etc.  Usually  the  upper  part  of  the  gut  makes  up  the  intussusceptum 
but  in  rare  instances  reverse  intussusception  occurs,  in  which  case  the  oppo- 
site condition  obtains. 

.Etiology.  Intussusception  is  seen  most  frequently  in  children  under  a 
year  old  but  is  not  unknown  in  adult  life.  As  a  cause  of  obstruction  it  is  nearly 
as  common  as  strangulation.  It  is  predisposed  to  by  diarrhoea  and  consti- 
pation, and  while  its  actual  cause  is  not  well  understood,  it  probably  results 
when  one  portion  of  the  bowel,  due  to  some  nervous  distxirbance,  suddenly 
contracts  while  a  neighboring  segment  remains  relaxed.  Intussusception 
just  ante  mortem  frequently  takes  place  and  the  condition  is  found  on  autopsy 
without  having  caused  symptoms  during  life. 

Pathology.  Inflammatory  processes  arising  in  the  serous  surfaces  of  the 
bowel  brought  into  contact  by  the  invagination  may  set  up  adhesions  also 
permanent  attachment  between  intussusceptum  and  intussuscipiens.  And 
the  invaginated  portion  may  necrose  and,  the  adhesions  being  of  such  character 
as  to  prevent  exit  of  the  intestinal  contents  into  the  abdominal  cavity,  being 
passed,  spontaneous  recovery  may  take  place.  In  other  instances  the  adhesions 
being  insufficient  the  sloughing  may  result  in  rupture  with  general  peritonitis. 

Symptoms.  The  first  of  these  are  sudden  pain  and  vomiting.  The  pain 
is  usually  paroxysmal  and  very  severe  in  character;  as  a  rule  it  is  not  distinctly 
localized  although  in  some  patients  it  may  be  referred  to  the  umbilical  region. 
It  is  most  severe  during  the  first  2  or  3  days  of  the  attack,  later  it  becomes 


420         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

less  marked.  The  vomiting  is  usually  persistent  and  difficult  of  control,  it 
may  be  projectile  in  character  but  is  rarely  faecal  in  infants,  though  in  older 
children  it  may  become  so.  Bloody  stools  with  mucus  are  a  frequent  symptom 
in  children  and  when  the  intussusception  involves  the  rectum  tenesmus  is  a 
common  manifestation. 

The  constitutional  symptoms  are  those  of  marked  prostration,  with  muscular 
relaxation,  pallor,  cold  extremities  and  subnormal  temperature,  which  late 
in  the  disease  may  rise  as  high  as  104°  F.  (40°  C.) 

Examination  shows  the  presence  of  a  "  sausage-shaped  "  abdominal  tumor 
in  the  majority  of  instances,  and  when  the  lower  colon  is  involved  it  may  be 
possible  to  feel  the  intussusceptum.  It  resembles  the  cervix  uteri  and  may  even 
protrude  for  an  inch  or  two.  There  may  be  a  depression  in  the  right  iliac  fossa 
(Dance's  sign).  Measuring  the  circumference  of  the  abdomen  from  hour  to 
hour  is  important  in  the  diagnosis  of  obstruction;  if  the  abdomen  gradually 
becomes  larger  is  strong  probability  of  its  existence. 

The  affection  may  terminate  by  spontaneous  reduction  or  by  sloughing 
of  the  invaginated  gut  rupture  of  the  intestine  being  guarded  against  by 
adhesions.  Death  from  shock  may  take  place — in  the  more  acute  instances — 
from  peritonitis,  or  from  exhaustion. 

Treatment  consists  in  attempts  at  reduction  by  means  of  inflation  of  the 
intestine  or  the  injection  of  fluids.  When  these  measures  are  ineffectual 
immediate  laparotomy  is  necessary. 

Inflation  is  practiced  by  means  of  a  soft  rubber  catheter  to  which  an  ordinary 
bellows  is  attached.  The  air  should  be  forced  in  very  gently  and  may  be 
prevented  from  escaping  by  compressing  the  nates.  The  hand  should  be 
kept  upon  the  abdomen  to  determine  the  degree  of  tension  of  the  intestine. 
If  reduction  follows,  rumbling  sounds  may  be  detected  and  the  tumor  may 
disappear,  but  often  there  is  no  proof  of  the  success  of  the  treatment;  here  the 
air  should  be  permitted  to  flow  out  and  a  thorough  manual  examination  of 
the  abdomen  undertaken.  Even  then  the  continuance  or  the  remission  of 
the  symptoms  is  the  only  index  of  the  efficacy  of  the  procedure.  Anaesthesia 
is  necessary  for  the  proper  carrying  out  of  this  mode  of  treatment  unless  the 
abdomen  is  greatly  relaxed. 

The  injection  of  fluids  is  a  legitimate  method  of  treatment  and  is  preferred 
by  some  to  inflation.  Either  normal  saline  solution  or  milk  and  water  at  a 
temperature  of  from  100°  to  105°  F.  (37.4°-4o.5°  C.)  may  be  employed.  The 
injection  is  given  from  a  fountain  syringe  placed  about  5  feet  above  the  patient 
and  through  a  soft  catheter,  the  exit  of  the  fluid  being  prevented  by  com- 
pression of  the  buttocks.  Inversion  of  the  patient,  if  a  child,  should  be 
practiced  at  intervals.  The  fluid  should  be  allowed  to  flow  for  about  a  quarter 
of  an  hour,  then  it  may  be  permitted  to  escape.  Whether  reduction  has  been 
accomplished  may  then  be  determined  as  after  inflation. 


OBSTRUCTION    BY    FOREIGN    BODIES.  •  42 1 

The  after  treatment  consists  in  absolute  rest  in  bed  and  the  administration 
of  moderate  doses  of  opium  for  several  days.  No  laxatives  should  be  admin- 
istered during  this  period  and  the  diet  should  consist  entirely  of  fluids. 

Unfortunately  a  recurrence  of  the  intussusception  not  infrequently  takes 
place. 

5.  Obstruction  by  Foreign  Bodies  or   Abnormal   Intestinal  Contents. 

The  most  common  cause  of  this  form  of  obstruction  is  a  biliary  calculus; 
other  foreign  bodies  such  as  coins,  fruit  pits,  buttons,  intestinal  parasites, 
enteroliths,  etc.,  may  be  mentioned  but  are  much  more  infrequently  causes 
of  intestinal  occlusion.  This  variety  of  obstruction  takes  place  in  most  in- 
stances in  the  small  intestine,  not  infrequently  at  the  ileo-coecal  valve. 

The  symptoms  so  closely  resemble  those  described  under  the  sections 
devoted  to  other  types  of  occlusion  as  to  need  no  separate  discussion. 

6.  Strictures  and  New  Growths. 

Obstructions  due  to  these  causes  are  rare  and  occur  chiefly  in  adults  beyond 
middle  life.  They  seem  to  be  more  common  in  females  than  in  males  and 
are  met  usually  in  the  large  intestine.  Cicatricial  strictures  follow  healed 
ulcers  especially  those  due  to  tuberculosis.  Syphilitic  stricture  of  the  rectum 
also  has  been  observed. 

Annular  stricture  of  the  intestine,  and  particularly  of  the  rectum  occurs  in 
intestinal  cancer  of  the  colloid  type  and  also  in  cylindrical-celled  epithelioma 
(see  the  section  on  intestinal  cancer,  p.  432).  Various  benign  neoplasms  of 
the  bowel  may  cause  occlusion,  and  tumors  external  to  the  intestine  and  inflam- 
matory processes  of  the  neighboring  structures,  by  pressing  upon  the  gut, 
may  cause  obstruction. 

7.  Obstruction  Due  to  Faecal  Impaction. 

Faecal  obstruction  as  a  result  of  chronic  constipation  or  paralysis  of  the 
intestinal  musculature  is  not  infrequent.  Its  most  common  site  is  low  in  the 
large  intestine  and  it  is  seen  more  often  in  old  persons  and  in  women  rather 
than  in  men. 

.Etiology.  This  condition  is  predisposed  to  by  chronic  constipation  and  by 
chronic  intestinal  and  peritonaeal  inflammations.  It  is  particularly  frequent 
in  the  insane  and  in  hysterical  and  neurasthenic  individuals.  Its  usual  site 
is  the  large  intestine,  particularly  the  coecum  and  sigmoid  flexure.  The  mass 
of  faeces  gradually  accumulating  in  atonic  conditions  of  the  intestine  becomes 


422       DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITON.EUM. 

dry  and  firm  and  sets  up  irritation  of  the  intestinal  lining.  The  intestinal 
musculature  above  the  impaction  may  undergo  hypertrophy  and  the  internal 
irritation  may  spread  to  the  peritona^al  coat  of  the  gut,  resulting  in  a  local 
peritonitis. 

Symptoms.  Of  these  the  most  important  is  an  increasing  constipation. 
The  abdomen  is  distended  and  tympanitic.  The  breath  is  foul,  the  tongue 
coated  and  the  patient  feels  weak  and  languid.  Examination  reveals  a  fascal 
tumor  situated  in  the  coecal  region  or  other  part  of  the  colon  with  distention 
in  the  coecum  or  iliac  fossa  (Bouveret's  sign).  The  mass  is  more  or  less  firm 
but  may  be  indented  by  pressure.  If  it  is  in  the  sigmoid  flexure  it  may  consist 
of  a  number  of  separate  masses;  in  the  colon  proper  it  is  likely  to  be  sausage- 
shaped  and  of  varying  length.  Patients  of  this  type  with  partial  occlusion  are 
subject  at  any  time  to  complete  obstruction  with  its  attendant  symptoms. 

The  Treatment  of  Intestinal  Obstruction  in  General. 

The  difficulty  in  the  treatment  of  this  condition  is  to  determine  when  oper- 
ative interference  may  be  postponed  and  internal  treatment  relied  upon. 
In  general  it  may  be  stated  that  when  there  is  reason  to  suspect  strangulation, 
operation  should  be  done  at  once  and  that  internal  measures  may  be  employed 
only  in  such  patients  as  give  no  evidence  of  abnormal  circulatory  conditions. 
Increased  pulse  frequency  and  vascular  tension  are  contra-indications  to  con- 
servative methods  of  treatment.  In  other  words,  instances  of  obstruction 
due  to  foreign  bodies  and  faecal  impaction,  when  the  constitutional  condition 
is  unaffected,  may  receive  internal  treatment,  and  patients  in  whom  the 
obstruction  is  manifestly  due  to  strangulation  or  volvulus  should  be  put 
into  the  hands  of  the  surgeon  at  once. 

The  question  as  to  how  long  unsuccessful  medical  treatment  may  be  contin- 
ued is  also  important.  The  answer  to  this  naturally  depends  upon  the  same 
factors  as  does  the  decision  as  to  whether  or  not  medical  means  are  justifi- 
able, namely,  upon  the  patient's  condition.  It  may  be  definitely  stated  that 
surgical  interference  should  be  delayed  not  longer  than  three  days  at  most, 
and  may  become  indicated  after  a  much  shorter  period  should  the  heart  and 
circulatory  apparatus  exhibit  symptoms  of  weakness. 

Having  decided  that  internal  treatment  may  be  employed  remains  the 
decision  as  to  of  what  this  may  consist.  The  means  suggested  for  the  med- 
ical management  of  intestinal  obstruction  have  been  many  and  of  these  the 
most  approved  will  be  discussed. 

Drugs.  Opium  is  opposed  by  many,  and  especially  by  surgical  authorities 
on  the  ground  that  it  induces  an  apparent  improvement  and  obscures  symp- 
toms which,  if  unaffected  by  the  drug,  would  indicate  operation;  consequently 
opium  should  be  given  only  in  the  earliest  stages,  when  the  pain  is  unendurable 


THE    TREATMENT    OF    INTESTINAL    OBSTRUCTION    IN    GENERAL.     423 

and  when  a  probable  diagnosis  is  impossible.  Here  a  hypodermatic  injection 
of  J  to  -J  of  a  grain  (0.016-0.022)  of  morphine  sulphate  is  admissible.  Follow- 
ing this  a  second  dose  may  be  given  if  no  relief  is  experienced. 

Atropine  recently  has  been  advocated  in  the  treatment  of  ileus  but  statistics 
are  insufficient  to  justify  any  positive  statement  as  to  its  efficacy.  The  prin- 
ciple on  which  is  has  been  administered  is  based  upon  its  supposed  anti- 
spasmodic effect  upon  the  intestinal  musculature.  It  may  be  given  in  moder- 
ate doses,  yI^  to  g^o  of  a  grain  (0.0005-0.001)  and  hypodermatically  three 
or  four  times  in  24  hours. 

Purgatives  are  distinctly  contra-indicated  in  intestinal  obstruction  unless 
an  absolutely  certain  diagnosis  of  faecal  impaction  can  be  made.  In  the 
latter  case  laxatives  may  be  given;  of  these  perhaps  calomel  in  repeated  doses 
of  J  to  ^  a  grain  (0.016-0.032)  is  to  be  preferred.  Treatment  by  high  rectal 
injections  of  warm  water  in  considerable  quantity,  retained  as  long  as  possible 
and  repeated,  frequently  if  necessary,  is  also  indicated.  Low  rectal  impac- 
tions may  be  removed  by  the  finger  or  a  blunt  instrument. 

Metallic  mercury  in  large  amounts  is  an  old  form  of  treatment  but  one 
which  is  dangerous  and  consequently  should  be  employed  with  the  utmost 
caution  if  at  all. 

Gastric  lavage  should  be  employed  in  all  patients,  even  in  those  to  be  imme- 
diately operated  upon.  In  these  latter  by  this  means  the  possibility  of  vomiting 
during  anaesthesia  is  greatly  lessened.  The  lavage  relieves  the  distressing 
vomiting  and  has  been  known  to  relieve  the  obstruction.  One  should  not  be 
content  with  one  washing  but  the  process  should  be  frequently  repeated  to 
disembarrass  the  stomach  of  the  often  rapidly  regurgitated  intestinal  contents. 
The  good  effect  of  this  procedure  is  more  marked  in  obstruction  of  the  small 
intestine.  Rectal  enemata  are  of  value  in  obstruction  due  to  fascal  impaction 
and  intussusception.  They  may  also  be  employed  in  other  forms  of  acute 
occlusion  in  the  hope  that  the  resulting  stimulation  of  peristalsis  may  cause 
a  reduction  of  the  ileus.  Enemata  if  ice  water  are  a  more  active  peristaltic 
stimulant  than  those  of  warm  water  but  must  be  given  with  care  especially 
if  there  is  any  tendency  to  collapse.  Irritating  solutions  have  been  recom- 
mended in  invagination,  especially  solutions  of  salt  (5  to  8  percent.)  and 
good  results  are  reported  from  their  use.  Inflation  with  air  (see  p.  420)  may 
also  be  found  advantageous. 

Massage  should  be  employed  only  in  intussusception  and  faecal  impac- 
tion and  here  only  with  the  greatest  care.  It  is  distinctly  contra-indicated 
when  peritonitis  is  suspected  and  in  patients  in  whom  the  obstruction  is  of  long 
standing,  since  here  there  is  a  possibility  of  gangrenous  conditions  which  may 
easily  be  ruptured. 

Electricity — chiefly  the  faradic  current  with  both  poles  applied  to  the 
abdomen — may  prove  effectual  in  stimulating  peristalsis  in  instances  of  faecal 


424         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

accumulation,  and  is  said,  at  times,  to  exert  a  beneficial  influence  in  volvulus. 
It  is,  however,  a  method  of  treatment  of  little  importance. 

The  application  of  cold  and  warm  compresses  or  poultices  to  the  abdomen 
may  relieve  the  patient's  pain  to  some  extent  but  is  absolutely  useless  as  a 
method  of  treatment  of  the  lesion  itseK. 

Diet.  In  acute  intestinal  obstruction  no  food  whatever  should  be  allowed. 
The  thirst  may  be  relieved  by  sucking  bits  of  ice  or  better  by  frequently  inject- 
ing small  quantities  of  brandy  and  water  into  the  rectum  or  by  enemata  of 
water  at  body  temperature,  since  when  ice  is  allowed  to  dissolve  in  the  mouth 
the  patient  is  continually  swallowing  water  in  unknown  amount.  There 
is  no  contra-indication  to  frequent  rinsing  of  the  mouth. 

The  collapse,  if  present,  may  be  combated  by  hypodermatic  stimulation. 

A  description  of  the  technique  of  the  surgical  operations  adapted  to  the 
radical  treatment  of  intestinal  obstruction  is  beyond  the  scope  of  a  work  of 
this  character. 

ENTEROPTOSIS. 

See  section  on  visceroptosis  (p.  380). 

CONSTIPATION. 

Synonyms.     Costiveness;  Coprostasis. 

Definition.     Infrequent  or  difficult  evacuation  of  the  faeces. 

The  normal  human  being  should  have  as  a  rule,  one  intestinal  evacuation 
every  24  hours.  There  are,  however,  individuals,  apparently  in  perfect  health, 
who  habitually  have  a  movement  of  the  bowels  only  every  other  day,  while 
certain  others  regularly  go  to  stool  twice  each  day. 

Pathology.  Post  mortem  examination  of  the  bodies  of  persons  who  during 
life  have  suffered  from  habitual  constipation  reveals  no  characteristic  lesion. 

.etiology.  Constipation  has  manifold  causes.  Among  the  factors  that 
are  potent  in  producing  the  condition  are: 

a.  InsuflSicient  peristaltic  action  of  the  intestinal  wall.  This  is  a  result 
of  atony  of  the  large  intestine,  which  condition  is  often  brought  about  by 
suppressing  the  inclination  to  go  to  stool,  by  chronic  intestinal  inflammations, 
the  wasting  diseases  and  lack  of  muscular  exercise. 

b.  Dryness  of  the  intestinal  contents  resulting  from  deficiency  in  the  secre- 
tion of  the  intestinal  fluids,  especially  the  bile. 

c.  Weakness  of  the  muscles  of  the  abdomen  due  to  over-stretching  of  these 
structures  as  in  conditions  of  obesity,  after  pregnancy,  etc. 

d.  Errors  in  diet.  Foods  leaving  little  undigested  residue  behind,  such 
as  milk,  concentrated  meat  soups  and  jellies,  tea  and  claret,  because  of  their 


CONSTIPATION.  425 

content  of  tannin,  are  prone  to  cause  constipation,  especially  when  little  water, 
which  taken  in  proper  quantity  moistens  the  intestinal  contents  and  increases 
secretion,  is  drunk.  Indigestible  foods,  irregular  meals,  and  insufficient 
mastication  also  increase  any  tendency  to  costiveness. 

e.  Partial  stenoses  of  the  bowel  caused  from  within  or  from  without  by 
the  pressure  of  displaced  organs,  abdominal  effusions,  peritonaeal  bands  or 
adhesions   interfere  with  the  normal  passage  of  faecal  matter. 

Symptoms.  These  may  be  indefinite  or  unrecognizable  but  in  a  consider- 
able number  of  patients  the  condition  results  in  a  variety  of  manifestations  such 
as  a  coated  tongue,  bad  breath,  lack  of  appetite,  headache,  torpor  and  poor 
digestion.  Uterine  and  ovarian  troubles  are  accentuated  by  constipation,  and 
pressure  on  the  veins  of  the  rectum  by  the  masses  of  hardened  faeces  often 
causes  haemorrhoids. 

Diarrhoea,  especially  in  the  aged,  may  co-exist,  since  loose  stools  caused  by 
irritation  from  the  faecal  masses,  may  make  for  themselves  a  passage  through 
or  alongside  the  impaction. 

Treatment.  Each  patient  should  be  separately  studied  and  the  cause  of  the 
constipation,  if  possible,  ascertained.  This  having  been  done  the  treatment 
becomes  simplified.  When  diet  and  regulation  of  the  patient's  habits  can  be 
relied  upon  to  relieve  the  condition  drugs  should  not  be  employed. 

The  patient  should  be  advised  to  go  to  stool  at  a  certain  hour  each  day 
no  matter  if  there  is  no  inclination  on  the  part  of  the  bowels  to  move,  for, 
if  the  intestine  acquires  the  habit  of  evacuating  itself  at  a  regular  time,  fre- 
quently the  mere  act  of  sitting  upon  the  stool  will  induce  a  movement.  He 
should  also  be  advised  always  to  heed  any  inclination  to  defaecate,  at  what- 
ever time  it  may  occur. 

A  regular  course  of  muscular  exercise  should  be  prescribed,  especially  for 
individuals  who  are  accustomed  to  a  sedentary  life.  The  daily  use -of  light^ 
dumb  bells  or  the  so-called  "setting  up"  exercises  are  very  efficient;  such 
movements  as  bending  backward  and  forward  from  the  hips,  rotating  the 
body  from  the  hips,  rising  to  a  sitting  posture  with  the  lower  limbs  fixed  while 
lying  down,  etc.,  are  an  excellent  means  of  strengthening  the  abdominal  muscles 
and  restoring  the  tonus  of  the  intestinal  muscularis.  Bicycling,  horseback 
riding,  golf  and  tennis  are  to  be  recommended. 

The  diet  should  consist  to  a  great  extent  of  such  foods  as  leave  behind  a 
considerable  undigested  residue,  such  as  fruits  of  all  kinds,  eaten  with  the 
skins  when  this  is  possible,  and  the  green  vegetables.  Brown  or  whole  wheat 
bread  is  preferable  to  white,  and  gingerbread  maybe  found  useful  in  children. 
Honey  is  laxative  as  also  is  molasses.  Highly  seasoned  foods,  milk,  eggs, 
pastry  and  fried  foods  are  constipating.  A  considerable  quantity  of  water 
should  be  taken  daily;  a  glass  should  be  drunk  while  dressing  in  the  morning 
and  another  at  night  before  retiring,  with  several  more  during  the  day.     Tea 


426         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

and  red  wines  should  be  forbidden.  Coffee  as  well  as  beer  and  cider  may  be 
allowed. 

Medicinal  treatment  should,  as  far  as  possible,  be  avoided,  but  it  is  often 
found  necessary  to  employ  the  milder  laxative  drugs.  Of  these  rhamnus 
purshiana  holds  the  first  place.  Its  chief  advantage  is  that,  less  than  other 
drugs  of  this  class,  its  continued  use  is  likely  to  necessitate  increased  dosage, 
owing  to  the  establishment  of  a  tolerance  on  the  part  of  the  patient;  in  addi- 
tion it  has  a  tonic  effect  upon  the  intestine.  Its  great  disadvantage  is  its  very 
unpleasant  taste,  but  this  can  be  obviated  by  its  exhibition  in  tablet  form 
and  by  the  use  of  various  palatable  preparations  which  may  be  procured. 
The  dose  of  the  fluidextract  is  from  ^  to  i  drachm  (2.0-4.0)  or  more  given 
at  night  before  retiring.  Its  employment  may  be  continued  for  a  considerable 
period  the  dose  being  gradually  lessened  as  the  tendency  to  constipation 
disappears.  Aloes  or  its  active  principle  aloin  is  another  excellent  drug 
of  the  same  class.  It  may  be  given  in  various  combinations  of  which  the 
following  example  may  prove  useful.  I^  aloini,  oleoresinae  podophylli, 
extracti  belladonnae,  of  each  gr.  |  (0.008);  make  one  pill.  This  pill  taken  at  bed 
time  usually  brings  about  a  natural  movement  the  next  morning,  and  seldom 
causes  griping  owing  to  the  belladonna.  Hyoscyamus  has  the  same  action 
in  this  regard  and  may  be  substituted. 

The  list  of  formulae  for  laxative  pills  might  be  made  almost  interminable 
but  it  is  needless  to  suggest  more  than  the  following:  I^  extracti  colocyn- 
thidis  compositi,  gr.  i  (0.065);  extracti  rhei,  gr.  iii  (0.20);  extracti  hyoscyami, 
gr.  ^  (0.033);  or  I^  aloini,  gr.  \  (0.004);  strychninae  sulphatis,  gr.  -gV  (o.ooi); 
extracti  belladonnae,  gr.  ^  (0.008);  or  I^  extracti  rhamni  purshianae,  gr.  ii  (0.13); 
oleoresinae  podophylli,  gr.  |  (0.008);  extracti  hyoscyami,  gr.  |  (0.033). 

For  patients  who  cannot,  or  who  think  they  cannot,  swallow  a  pill  the  time- 
honored  mixture  of  rhubarb  and  soda  combined  with  fluidextract  of  rhamnus 
purshiana,  5  minims  (0.33)  to  each  teaspoonful  (4.0)  may  be  prescribed. 
A  drachm  (4.0)  of  this  compound  before  each  meal  often  gives  good 
results. 

Synthetic  purgatives  such  as  purgatin  and  phenolphthalein  are  useful.  The 
dose  of  the  former  is  from  15  grains  to  ^  a  drachm  (1.0-2.0)  and  possesses 
the  disadvantage  that  it  may  irritate  the  kidneys.  The  latter,  given  in  tablet 
form  is  willingly  taken  by  children  since  its  taste  is  pleasant,  and  is  said 
to  bring  about  no  unpleasant  after-effects.  Its  dose  is  from  i  to  15  grains 
(0.065-1.0). 

When  an  atonic  condition  of  the  bowel  is  present  physostigmine  salicylate 
in  dosage  of  y^^  of  a  grain  (0.0006)  may  be  given  separately  or  added  to 
one  of  the  above  formulae. 

Compound  licorice  powder  in  drachm  (4.0)  doses  is  often  useful. 

The  stronger  purgatives  such  as  castor  oil,  calomel  and  the  various  salines 


CONSTIPATION.  427 

are  admissible  only  when  the  intestine  is  clogged  with  faecal  matter  that 
requires  immediate  removal. 

Laxative  mineraL  waters  should  not  be  taken  habitually  as  a  rule  but  in 
obesity,  chronic  lithaemic  conditions  and  hepatic  cirrhosis  their  occasional 
use  is  of  advantage.  The  waters  to  be  recommended  are  Carlsbad  Spriidel, 
Hunyadi,  Apenta,  Villacabras,-  that  of  Bedford  Springs,  Pennsylvania,  and 
Saratoga  Congress  water. 

The  treatment  of  constipation  at  the  various  spas  is  unsatisfactory.  During 
the  patient's  sojourn  at  the  water  cure  the  regular  life,  exercise  and  restricted 
diet,  together  with  the  water  drunk,  regulate  the  bowels  but  on  returning  home 
the  cure  is  found  to  be  by  no  means  permanent. 

The  continued  treatment  of  constipation  by  enemata  is  not  to  be  recom- 
mended. An  injection  is,  however,  a  most  approved  means  of  removing 
fascal  impactions  and  managing  the  attacks  of  obstinate  constipation  that 
at  times  occur  in  the  course  of  chronic  states  of  costiveness. 

The  injection  may  consist  of  lukewarm  water  or  of  soap  suds.  If  these  are 
ineffectual,  the  condition  can  probably  be  relieved  by  an  enema  of  8  ounces 
(250.0)  of  olive  or  cotton  seed  oil,  2  ounces  (60.0)  of  castor  oil,  turpentine 
spirit,  ^  ounce  (15.0)  to  the  pint  (500.0)  of  warm  water  or,  if  the  impaction  is 
particularly  obstinate,  a  mixture  of  i  drachm  (4.0)  of  ox  gall  in  a  pint  (500.0) 
of  water. 

Rectal  enemala  should  be  given  from  a  fountain  syringe  suspended  4  or 
5  feet  above  the  patient  and  through  a  soft  rubber  rectal  tube  passed  high 
into  the  rectum.  The  Davidson  syringe  if  employed  should  be  used  with 
great  care,  especially  in  children  for  if  too  great  force  is  exerted  there  is  danger 
of  intestinal  rupture. 

Impactions  low  in  the  rectum  may  be  relieved  by  means  of  suppositories 
of  glycerin  or  such  as  the  following:  I^  glycerini,  rrLiii  (0.2);  pulveris  aloes, 
gr.  ^  (0.022);  extracti  belladonnae,  gr.  J  (0.016);  olei  theobromatis,  q.s.  ad,  gr. 
XV  (i.o). 

Massage  of  the  abdomen  is  an  excellent  adjunct  to  treatment  and  may  be 
performed  either  by  a  nurse  or  the  patient  himself.  The  manipulation 
should  be  commenced  in  the  region  of  the  splenic  flexure  of  the  colon  and 
carried  on  along  the  descending  colon  toward  the  rectum;  then  beginning 
at  the  hepatic  flexure  the  endeavor  should  be  made  to  unload  the  transverse 
colon;  finally  the  coecum  and  ascending  colon  are  masseed  and  the  seance  is 
ended  by  traversing  the  whole  colon  from  ileo-coecal  valve  to  sigmoid  flexure. 
The  patient  also  may  be  instructed  to  percuss  his  abdomen  with  the  ulnar 
border  of  the  hand  along  the  course  of  the  large  intestine  for  a  number  of 
minutes  night  and  morning.  A  vigorous  course  of  treatment  of  this  character 
may  succeed  where  drugs  have  failed.  Rolling  a  5  lb.  (2265.0)  shot  upon  the  ab- 
domen for  5  or  10  minutes  every  morning  has  been  recommended. 


428         DISEASES    or    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Hydrotherapeutic  measures  such  as  vigorous  friction  baths,  cold  or  alternate 
warm  and  cold  spinal  douches,  hip  baths  at  50°  to  68°  F.  (10°  to  20°  C.)  of 
from  2  to  5  minutes  duration  once  or  twice  a  day  and  a  wet  abdominal  com- 
press at  50°  F.  (10°  C.)  on  retiring  are  approved  additions  to  general 
hygienic  treatment. 

Electricity  in  the  form  of  the  faradic  current  may  be  employed  with  the 
object  of  causing  short  colonic  contractions.  One  electrode  may  be  applied 
to  the  back  while  the  other  is  pressed  deep  into  the  abdomen.  The  abdominal 
electrode  should  not  be  held  stationary  for  any  length  of  time,  but  its  situation 
should  be  rapidly  changed.  Static  electricity  in  the  form  of  the  wave,  or  the 
static  induced  current,  is  useful,  the  former  in  mild  constipation,  the  latter 
in  obstinate  chronic  instances.  When  the  static  wave-current  is  used  but  one 
pole  is  in  contact  with  the  patient,  the  other  being  grounded  or  not;  if  the 
latter,  the  treatment  is  milder  than  when  the  former  is  the  case.  The  current 
is  transmitted  to  the  patient  either  through  a  rectal  electrode  or  a  flat  electrode 
applied  to  the  wall  of  the  abdomen,  its  strength  being  regulated  by  the  spark- 
gap  between  the  sliding  poles. 

In  using  the  static  induced  current  the  patient  is  connected  with  the  outer 
surface  of  the  Leyden  jars,  their  inner  surfaces  being  connected  with  the 
poles  of  the  machine.  One  electrode  is  placed  upon  the  back,  the  other  in 
the  rectum,  or  both  are  applied  to  the  back. 

The  treatment  of  constipation  in  infants  is  dietetic  when  it  is  possible  to 
combat  the  condition  by  this  means.  Fortunately  in  breast-fed  babies  the 
condition  is  rare.  In  bottle-fed  children  the  regulation  of  the  proper  propor- 
tion of  fat  and  proteid  will  overcome  the  difficulty.  Very  often  raising  the  fat 
percentage  or  reducing  that  of  proteid  is  all  that  is  necessary.  If  the  consti- 
pation is  obstinate  the  use  of  an  occasional  teaspoonful  of  olive  oil  in  conjunc- 
tion with  abdominal  massage  and,  if  necessary,  the  employment  now  and  then 
of  a  suppository  constructed  of  a  cone  of  oiled  paper  may  prove  successful. 
Suppositories  of  soap  or  glycerin  are  irritating  to  the  rectum  but  those  of  gluten 
do  not  possess  this  disadvantage  and  may  at  times  be  used  with  benefit.  If 
laxative  medicines  are  necessary  young  infants  may  be  given  a  few  grains  of 
sodium  phosphate  or  a  teaspoonful  or  two  of  milk  of  magnesia  may  be  added 
to  the  last  bottle  at  night. 

The  management  of  constipation  in  older  children  should  be  carried  out 
along  the  same  lines  as  those  suggested  in  its  treatment  in  adults;  the  estab- 
lishment in  early  life  of  a  regular  habit  of  going  to  stool  is  most  important. 

COLITIS. 

Most  of  the  Diseases  of  the  Colon  are  caused  by  infections.  Reference 
should  be  made  to  the  section  upon  Infectious  Diseases. 


DILATATION    OF    THE    COLON.  429 

DILATATION  OF  THE  COLON. 

This  condition  occurs  in  both  an  acute  and  a  chronic  form;  the  first  as  a 
result  of  acute  obstruction,  the  second  as  a  sequel  of  chronic  constipation 
or  atony  of  the  bowel.  Colonic  dilatation  is  also  observed  as  a  congenital 
defect.  Here  it  usually  affects  the  descending  portion  or  the  sigmoid  flexure 
and  is  a  factor  in  the  production  of  constipation  later  in  life. 

Pathology.  Any  part  of  the  colon  or  its  whole  length  may  be  dilated.  In 
chronic  instances  the  muscular  coat  may  be  thickened,  in  acute  instances  the 
whole  intestinal  wall  may  be  thin  as  a  result  of  stretching  or  atrophy. 

Sjrmptoms.  There  is  obstinate  constipation,  marked  abdominal  distention 
and  often  pressure  upward  upon  the  liver,  spleen,  and  thoracic  viscera.  In 
severe  instances  the  action  of  the  heart  and  lungs  may  be  greatly  embarrassed, 
sudden  death  even  having  occurred  as  a  result  of  interference  with  the  heart. 
In  more  acute  instances  vomiting  may  be  present.  Examination  reveals  an 
abdomen  greatly  distended  and  markedly  tympanitic,  hepatic  and  splenic 
dulness  often  being  obscured. 

Treatment  consists  in  relieving  the  constipation  by  high  enemata,  in 
obstinate  instances,  of  oil  or  ox  gall  (see  p.  427)  if  necessary.  These  should  be 
given  in  connection  with  drug  medication  given  by  mouth  with  a  view  to  over- 
coming the  obstructive  condition  from  above.  Having  emptied  the  bowel, 
remains  to  bring  about  as  normal  an  intestinal  action  as  possible.  This 
may  be  accomplished  by  the  administration  of  laxatives,  castor  oil  now  and 
then  being  very  effectual,  the  prevention  of  distention  by  means  of  antifer- 
mentives  such  as  bismuth  tetraiodophenolphthaleinate,  gr.  v  (0.33)  with 
resorcinol,  gr.  ii  (0.13),  beta-naphthol,  gr.  xv  (i.o)  or  bismuth  naphtholate,  gr. 
X  (0.66). 

The  administration  of  physostigmine  salicylate — gr,  y^^  (0.0006)  or  of 
strychnine  sulphate — gr.  -3V  (0.002)  is  useful  in  restoring  the  normal  tonicity 
of  the  bowel. 

One  should  always  make  a  digital  exploration  of  the  rectum,  for  manual 
removal  of  faecal  impaction  is  often  necessary. 

The  diet  should  be  easily  digestible,  such  as  to  cause  as  little  fermentation 
as  possible  and  composed  of  foods — meat  in  particular — that  leave  little 
residue  behind. 

Surgical  procedures  such  as  the  formation  of  an  artificial  anus  or  resection 
of  considerable  portions  of  the  bowel,  when  indicated,  have  given  good  results. 

NERVOUS  AFFECTIONS  OF  THE  INTESTINES. 

Of  these  we  may  distinguish  three  types: 

a.  Motor  disorders. 

b.  Sensory  disorders. 


430         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

c.  Secretory  disorders.  ' 

Of  motor  disorders  there  are  three  classes: 

1.  Increased  peristaltic  activity  of  both  small  and  large  intestine  re- 
sulting in  the  so-called  nervous  diarrhoea;  there  is  also  probably  an  increased 
intestinal  secretion  as  well.  The  condition  is  seen  most  often  in  neurotic 
and  hysterical  patients  and  after  unusual  mental  shocks,  such  as  may  be 
caused  by  sudden  fright,  joy,  etc.  There  is  no  pathological  change  in  the 
intestine;  the  attacks  of  diarrhoea  appear  without  warning  and  may  cease 
suddenly.  The  stools  vary  in  frequency  from  2  to  15  or  20  during  the  day 
and  are  composed  of  thin  watery  matter,  mucus  being  seldom  present  and 
blood  still  more  rarely.  During  the  defaecation  there  may  be  a  considerable 
expulsion  of  gas,  tenesmus  and  intestinal  rumblings. 

2.  Peristaltic  unrest  or  tormina  intestinorum  chiefly  involves  the  small 
intestine  and  consists  of  peristaltic  waves  passing  from  one  end  of  the  bowel 
to  the  other  and  carrying  with  them  whatever  of  gas  or  fluid  may  be  present. 
The  condition  occurs  both  in  neurotic  and  in  perfectly  healthy  subjects  and 
concerning  its  cause  we  can  but  advance  the  theory  that  it  is  the  result  of  a 
hyper-excitability  or  an  increased  activity  on  the  part  of  the  nervous  mech- 
anism which  presides  over  peristalsis. 

The  excessive  peristalsis  may  follow  emotional  shocks,  occur  at  the  men- 
strual epoch  or  without  assignable  cause.  An  attack  usually  lasts  but  a  few 
minutes  but  may  be  prolonged  for  hours.  It  is  evidenced  by  very  percep- 
tible rumbling  and  gurgling  sounds  in  the  abdomen,  varying  in  intensity. 
Pain  is  rare  but  the  patient  is  usually  distressed  because  of  the  embarrassing 
amount  of  attention  attracted  by  the  affection. 

3.  Nervous  cramp  or  enterospasm  is  an  obscure  affection  consisting  of  a 
contraction  of  the  intestine  limited  to  a  small  portion  of  the  bowel  or  involving 
a  considerable  length  of  this  structure.  The  spasm  is  characterized  by  pain 
lasting  for  variable  periods;  there  may  be  localized  distention  of  the 
bowel. 

4.  Intestinal  paralysis  apparently  results  from  over-irritation  of  the 
inhibitory  nerves  of  the  intestinal  muscularis  which  may  finally  undergo 
atrophy.     The   condition,  when   chronic,  produces   habitual   constipation. 

The  treatment  of  the  increased  peristaltic  activity  consists  in  the  employ- 
ment of  means  calculated  to  combat  the  nervous  and  hysteric  states  from 
which  the  condition  results.  Constipating  drugs  have  no  effect.  Success 
may  attend  the  use  of  the  bromides  and  arsenic  together  with  the  regulation 
of  the  mode  of  life  and  attention  to  general  hygiene. 

Of  the  treatment  of  peristaltic  unrest  the  same  can  be  said  as  regards  general 
management;  spa  or  institutional  treatment,  with  electricity  and  hydrothera- 
■peutic  procedures  as  adjuncts,  often  achieves  good  results.  With  regard  to 
drugs,  arsenic,  the  bromides,  valerian,  codeine  and  belladonna  have  been 


NERVOUS    AFFECTIONS    OF    THE    INTESTINES.  43 1 

recommended,  with  hydrated  chloral  and  opium  as  last  resorts.  These 
last  two  must  be  used  with  great  care  lest  the  patient  become  a  drug 
habitue. 

In  enterospasm  all  methods  of  treatment  which  increase  intestinal  irri- 
tability, such  as  electricity,  massage,  cold  applications  and  the  like,  must  be 
avoided.  Marked  constipation  occurring  with  this  condition  should  be 
relieved  by  oil  injections,  and  the  local  application  of  warm  compresses  and 
the  employment  of  warm  baths  are  approved  methods  of  treatment.  The 
administration  of  various  drugs  has  been  suggested  with  the  view  to  lessening 
the  irritability  of  the  intestine;  of  these  opium,  belladonna,  acetphenetidine 
(phenacetine)  and  antipyrine  may  be  mentioned. 

Intestinal  paralysis  should  be  treated  by  the  administration  of  strychnine 
sulphate  in  considerable  doses — gr.  -^-^  to  -jV  (0.002-0.003) — 3  times  a  day 
and  by  other  measures  calculated  to  stimulate  and  restore  the  tone  of  the 
intestinal  musculature,  such  as  massage  and  electricity. 

Sensory  disorders.  Intestinal  neuralgia  is  a  painful  affection  resulting 
from  a  hyper-sensitiveness  of  the  sensory  nervous  mechanism  of  the  bowel. 
The  condition  is  distinct  from  the  pain  of  true  colic  and  is  seen  in  nervous 
and  hysterical  individuals,  certain  nervous  diseases,  especially  locomotor 
ataxia  (tabetic  intestinal  crises),  in  gouty  conditions  and  as  a  result  of  chronic 
plumbism.  The  pain  is  general,  involves  the  whole  abdomen,  and  is  of 
extremely  severe  type.  It  is  increased  on  pressure.  Its  diagnosis  is  very 
difficult,  there  being  so  many  painful  abdominal  affections  from  which  it 
must  be  differentiated  that  at  times  an  exploratory  laparotomy  is  the  only 
means  by  which  the  condition  can  be  certainly  diagnosticated. 

Intestinal  hyperaesthesia  or  abnormal  sensations  in  the  bowel  occur  in 
hysterical  and  neurasthenic  patients.  Of  these  there  is  a  great  variety  ranging 
from  feelings  of  fullness,  tickling  or  throbbing  to  severe  burning  or  stabbing 
pain.  The  condition  is  the  result  of  some  disorder  of  the  central  nervous 
system  or  of  a  local  derangement  of  the  intestinal  innervation. 

The  treatment  of  both  these  conditions  resolves  itself  into  the  proper  man- 
agement of  any  neurotic  tendency  which  may  exist,  by  means  of  general 
measures  such  as  the  rest  ciire,  institutional  or  spa  treatment.  Belladonna 
may  afford  relief;  opium  should  never  be  given  on  account  of  the  danger  of 
habit  formation.  Sensory  disorders  due  to  tabes,  gout  or  plumbism  should 
receive  the.  treatment  which  their  causes  indicate. 

Secretory  disorders  are  the  result  of  vaso-motor  derangements  and  are  very 
difficult  to  separate  from  abnormalities  of  motility  and  sensation,  in  fact  these 
conditions  often  occur  simultaneously.  Certain  influences,  however,  may 
cause  excessive  outpouring  into  the  bowel  of  large  quantities  of  serous  or 
mucous  fluid.  The  management  of  such  conditions  has  been  discussed  under 
the  sections  on  the  treatment  of  nervous  diarrhoea. 


432         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

MALIGNANT  GROWTHS  OF  THE  INTESTINE. 

Carcinomata  may  occur  in  any  part  of  the  bowel.  They  involve,  in  by 
far  the  majority  of  instances,  the  rectum,  are  much  less  common  in  the  colon 
and  are  very  rare  in  the  small  intestine.  Various  types  of  cancer  have  been 
observed;  those  most  frequently  seen  in  the  small  intestine  are  cylindrical 
celled  epitheliomata  or  adeno-carcinomata  and  the  most  usual  site  of  the  neo- 
plasm is  in  the  duodenum  near  the  opening  of  the  bile-duct.  In  the  colon  we 
find  cylindrical  celled  epitheliomata;  the  situations  most  frequently  involved  are 
the  caput  coli  and  the  sigmoid  flexure.  In  the  rectum  malignant  new  growths 
are  of  more  varied  type,  colloid,  scirrhus  and  soft  carcinomata  as  well  as 
epitheliomata  of  the  squamous  celled  type  commonly  existing  in  this  situation; 
sarcomata  are  much  more  rare  but  do,  at  times,  occur. 

Symptoms.  These  are  by  no  means  typical.  The  usual  cancerous  cachexia 
is  usually  present,  if  not  at  first,  in  the  later  stages.  To  this  may  be  added  the 
symptoms  of  partial  obstruction  such  as  pain,  nausea,  vomiting  and  constipa- 
tion, with  the  presence  of  a  tumor.  This  last  varies  in  size  and  situation,  is 
usually  firm  in  consistency,  irregular  of  surface  and  generally  tender.  It  is  fre- 
quently movable,  but  this  is  not  always  the  case.  It  is  dull  on  percussion  and 
may  seem  to  pulsate  if  it  is  situated  over  the  aorta.  Masses  of  faecal  matter 
lying  above  it  in  the  bowel  may  obscure  the  tumor  but  the  administration  of 
irrigations  or  laxatives  will  remove  these,  after  which  the  true  character  of 
the  lesion  will  become  apparent. 

In  cancer  low  in  the  rectum  digital  examination  or  inspection  by 
means  of  the  proctoscope  will  reveal  the  presence  of  a  malignant  obstruc- 
tion. 

The  bowel  movements  are  constipated  in  character  as  a  rule  but  may  be 
otherwise  normal  in  rare  instances.  If  the  neoplasm  is  in  the  rectum  they  are 
likely  to  be  ribbon-  or  pencil-shaped  as  a  result  of  the  stenosis.  They  may 
contain  blood  and  more  or  less  foetid  pus,  the  former  both  before  and  after 
ulceration  has  taken  place,  the  latter  after  this  event  only.  The  presence 
of  mucus  signifies  little  else  than  that  an  inflammatory  condition  of  the  intes- 
tinal lining  is  present;  the  occurrence,  however,  of  sanious  pus  or  muco-pus 
is  of  extreme  importance  from  a  diagnostic  point  of  view  since  these  appear 
only  in  intestinal  cancer,  in  ulcerative  colitis  and  as  a  result  of  the  rupture  of 
an  abscess  into  the  lumen  of  the  bowel.  The  large  amount  of  the  pus  in  the 
last  case  and  the  unlikelihood  of  colitis  being  mistaken  for  malignant  intestinal 
tumor  simplify  the  differential  diagnosis  of  cancerous  conditions.  The  im- 
portance of  digital  rectal  examination,  however,  in  all  suspicious  instances 
cannot   be  over-estimated. 

The  separation  of  duodenal  cancer  from  pyloric  carcinoma  is  difficult, 
the  presence  of  jaundice,  lack  of  early  dyspeptic  symptoms  and  normal  acidity 


HEMORRHOIDS.  433 

of  the  gastric  contents  pointing  to,  but  not  rendering  certain,  the  existence 
of  the  former  condition. 

Non-malignant  tumors  of  the  intestine,  such  as  polyps,  fibromata, 
angiomata,  etc.,  may  exist  without  causing  symptoms;  they  may,  on  the  other 
hand,  produce  symptoms  resembhng  those  of  maHgnant  growths,  such  as  stools 
containing  mucus  and  blood;  there  is  no  resulting  cachexia  and  the  neoplasm 
may  be  seen  or  felt  upon  rectal  examination. 

The  treatment  of  cancers  of  the  bowel  consists  in  removal  of  the  growth  by 
surgical  procedure  when  this  is  possible.  The  operation  indicated  varies 
with  the  condition  present.  Resection  of  the  bowel  without  the  formation  of  an 
artificial  anus  has  prolonged  life  and  excellent  results  may  be  achieved  in 
favorable  instances  by  rectal  resection. 

When  surgical  intervention  is  for  any  reason  decided  against,  the  patient's 
general  condition  should  receive  attention.  His  noiirishment  should  be 
maintained  by  the  administration  of  easily  digested  foods  given  by  the  mouth 
or  per  rectum,  and  stimulants  should  be  prescribed  when  necessary.  The 
possibility  of  obstruction  by  faecal  matter  should  be  provided  against  by 
regulation  of  the  bowels  so  that  a  sufficient  movement  is  obtained  each  day. 

PROCTITIS. 

Proctitis  or  inflammation  of  the  mucous  lining  of  the  rectum  occurs  in 
various  types,  usually  as  a  part  of  co-existing  colonic  inflammation.  For  a 
description  of  these  conditions  and  their  treatment  the  reader  is  referred  to 
the  sections  upon  dysentery,  entero-colitis  and  intestinal  ulceration. 

HAEMORRHOIDS 

Synonym.     Piles. 

Definition.  Haemorrhoids  is  the  term  employed  to  designate  a  varicose 
condition  of  the  veins  of  the  lower  rectum.  Their  most  frequent  situation  is  at 
the  muco-cutaneous  junction  at  the  anal  orifice. 

Haemorrhoids  are  internal  or  external  depending  upon  whether  they  are 
developed  within  the  sphincter  ani  or  outside  this  muscle. 

Pathology.  The  hasmorrhoidal  tumor  is  composed  of  dilated  blood-vessels, 
of  clots  beneath  the  mucous  membrane  or  of  the  muco-cutaneous  integument 
of  the  anal  region.  It  is  seldom  single;  more  frequently  there  are  two  or 
more.  In  shape  they  are  spherical  or  ovoid,  of  the  size  of  a  small  pea  to  that 
of  a  good  sized  grape  or  even  larger;  in  color  they  are  reddish  or  purple,  their 
surface  is  smooth  or  lobulated,  and  in  consistency  they  vary  from  soft  and 
fluctuating  to  firm  and  tense.  On  section  they  are  found  to  be  filled  with 
venous  blood  and  if  of  long  standing  the  cavity  of  the  tumor  may  be  intersected 
with  a  reticular  growth  of  connective  tissue. 
28 


434         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Etiology.  Haemorrhoids  are  predisposed  to  by  the  erect  posture  of  the 
body  and  the  anatomical  arrangement  of  the  structures  involved;  the  fact  that 
haemorrhoidal  veins  drain  into  both  the  general  and  the  portal  venous  circu- 
lation renders  the  occurrence  of  piles  common  in  conditions  involving  venous 
obstruction,  such  as  cardiac  lesions,  hepatic  cirrhosis,  etc.  Haemorrhoids 
are  common  in  both  men  and  women;  the  former  seem  to  be  more  frequently 
affected  than  the  latter,  although  this  may  be  the  result  of  the  natural  disin- 
clination of  the  female  sex  to  consult  a  physician  concerning  such  a  condition. 

Chronic  constipation  is  a  common  predisposing  cause  of  hjemorrhoids,  the 
hard  faecal  masses  pressing  upon  the  veins  of  the  rectum  and  rendering  free 
circulation  difl&cult.  Pelvic  tumors,  uterine  displacements," etc.,  act  in  the 
same  manner  and  have  the  same  result;  haemorrhoids  are  a  common  and 
often  very  distressing  complication  of  pregnancy.  The  tendency  of  the 
menstrual  flow  to  relieve  congestion  of  the  pelvic  region  is  likely,  on  the  other 
hand,  to  militate  against  the  production  of  piles. 

Haemorrhoids  are  also  predisposed  to  by  the  wearing  of  over-tight  clothing 
about  the  waist,  by  over-eating  and  drinking  and  by  sedentary  habits. 

Symptoms.  Piles  may  exist  for  long  periods  without  causing  symptoms. 
Should  an  external  haemorrhoid  become  congested  for  any  reason  the  first 
symptom  is  pain  in  the  region  of  the  anus,  accompanied  by  sensations  of 
tingling;  these  increase  until  sitting  becomes  impossible  and  a  movement 
from  the  bowels  is  attended  with  excruciating  agony.  Examination  reveals 
one  or  more  purplish  tumors  at  the  anal  margin,  hard  and  tense  and  exces- 
sively tender.  The  tumor  may  gradually  disappear  and  the  symptoms  abate, 
abscess  formation  may  ensue  and  spontaneous  cure  result  after  rupture  and 
discharge  of  the  pus,  or  the  circulation  being  cut  off  by  the  engorgement,  the 
haemorrhoid  may  ulcerate  off.  At  any  time  inflammation  may  recur  with  its 
attendant  symptoms.  Recurrent  haemorrhage  from  the  tumors  is  not  infre- 
quent and  is  not  harmful  provided  not  too  much  blood  is  lost. 

Internal  piles  may  be  single  or  multiple.  The  symptoms  produced  by 
them  are  a  feeling  of  fulness  or  tenesmus  in  the  rectum,  with  dull  aching  pain 
and  perhaps  a  mucous  rectal  discharge.  Engorgement  with  symptoms 
corresponding  to  those  of  external  piles  may  at  any  time  appear  and  haemor- 
rhage is  not  uncommon;  this  latter  may  relieve  the  discomfort  but  at  times 
so  much  blood  is  lost  as  to  jeopardize  the  health  of  the  patient. 

Treatment  consists  in  attention  to  any  causative  factor  in  the  shape  of 
cardiac,  hepatic  or  pelvic  disease,  the  securing  of'  a  normal  movement  of  the 
bowel  each  day  (see  the  treatment  of  constipation,  p.  425)  and  careful  daily 
cleansing  of  the  parts  by  means  of  soap  and  warm  water.  Painful  haemor- 
rhoids when  not  acutely  engorged  may  be  relieved  by  various  astringents 
such  as  liquor  ferri  subsulphatis;  this  should  be  applied  2  or  3  times  daily 
with  a  brush.     Ointments  such  as  the  following  are  often  effectual:  I^  unguenti 


DISEASES    OF    THE    LIVER.  435 

stramonii,  unguenti  belladonnae,  aa.  3ii  (8.0);  unguenti  gallae,  3iv  (15.0);  or 
I^  extract!  suprarenalis,  5ii  (8-o);  adipis  lanae  hydrosi,  5vi  (24.0).  These 
ointments  should  be  applied  generously  to  the  affected  part,  a  wad  of  cotton 
should  be  fitted  over  the  anus  and  held  in  place  with  a  T-bandage. 

Inflamed  and  engorged  piles  may  be  relieved  by  holding  a  piece  of  ice  in 
contact  with  the  tumors,  by  spraying  them  with  a  jet  of  cold  water  or  by  apply- 
ing a  compress  of  gauze  impregnated  with  boroglyceride  or  by  ointments 
such  as  the  following:  I^  morphinae  sulphatis,  gr.  x  (0.66);  unguenti  bella- 
donnas, unguenti  stramonii,  aa  5iss(6.o);  ichthyons,5v  (20.0);  orl^  morphinae 
sulphatis,  gr.  iss  (o.i);  acidi  tannici,  5ss(2.o);  picis  Hquidae,  5ss(2.o);  cerati, 
5ss  (2.0);  adipis  benzoinati,  q.s.  ad  §i  (30.0). 

The  treatment  of  piles  which  are  not  protruded  is  practically  identical 
with  that  already  given.  The  diflSculty  of  applying  ointments  to  the  tumors 
within  the  sphincter  may  be  obviated  by  the  use  of  the  "pile  pipe,"  an  in- 
strument adapted  to  the  injection  of  semi-solid  materials,  and  the  employment 
of  suppositories;  of  these  the  following  excellent  examples  are  worthy  of 
trial:  I^  ichthyoHs,  acidi  tannici,  aa  gr.  v  (0.33);  extracti  belladonnae,  gr.  J 
(0.032);  extracti  hamameHdis,  olei  theobromatis,  q.s.  ad  gr.  xv  (i.o).  Fiat 
suppositoria;  I^  iodoformi,  gr.  v  (0.33);  olei  theobromatis,  gr.  x  (0.66).  Fiat 
suppositoria. 

Haemorrhage  from  protruded  piles  may  be  controlled  by  the  application  of 
a  wad  of  cotton  thoroughly  impregnated  with  iodoform,  powdered  supra-renal 
extract,  powdered  calomel,  bismuth  subgallate  or  aristol,  or  a  compress  saturated 
with  a  10  percent,  solution  of  calcium  chloride;  bleeding  from  the  non-protru- 
ded variety  may  be  stopped  by  the  injection  of  5  drachms  (20.0)  of  10  percent, 
calcium  chloride  solution  or  the  introduction  of  suppositories  such  as  the 
following:  I^  extracti  suprarenalis,  gr.  v(o.33);  olei  theobromatis,  gr.  x(o.66). 

For  a  description  of  the  treatment  of  haemorrhoids  by  injection  and  radical 
surgical  measures,  which  are  indicated  when  medicinal  treatment  fails,  the 
reader  is  referred  to  works  upon  rectal  diseases  or  upon  surgery. 

DISEASES  OF  THE  LIVER. 

ABNORMALITIES  IN  SHAPE  AND  POSITION  OF  THE  LIVER. 

The  most  common  and  important  abnormality  in  the  shape  of  the  liver 
is  the  result  of  the  constriction  of  tight  waist  bands  or  corsets,  the  so-called 
"corset"  or  "lacing  liver."  The  deformity  consists  of  a  division  of  the  right 
lobe  into  two  parts  by  a  transverse  groove  of  varying  depth.  At  times  the 
furrow  is  so  deep  that  the  right  lobe  is  divided  into  two  more  or  less  equal  por- 
tions by  a  tendinous  band.    The  symptoms  which  ensue  are  usually  unimpor- 


436        Di;3EASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

tant  the  chief  interest  of  the  condition  lying  in  the  fact  that  the  lower  division 
of  the  lobe,  which  often  reaches  to  the  umbilicus  and  may  extend  as  low  as 
the  iliac  crest,  is  likely  to  be  mistaken  for  an  abdominal  tumor  or  a  mis- 
placed kidney;  its  margin,  however,  in  most  instances,  is  continuous  with  that 
of  the  left  lobe  of  the  liver  and  the  displaced  organ  descends  with  inspiration. 
If  the  intestine  lies  in  the  groove  and  is  tympanitic  upon  percussion  there  is 
an  added  difficulty  in  the  differentiation  of  the  condition.  The  symptoms, 
if  any,  are  those  incident  to  the  dragging  down  of  the  tumor,  and  nervous 
manifestations,  such  as  those  caused  by  a  movable  kidney,  may  be  present. 

At  times  the  corset  liver  lies  almost  entirely  above  the  costal  margin,  it  is 
narrower  above  than  below  and  the  transverse  furrow  is  just  superior  to  the 
lower  margin  of  the  organ. 

These  deformities  of  the  liver  are  said  to  offer  an  obstruction  to  the  normal 
flow  of  the  bile  and  consequently  to  predispose  to  the  formation  of  hepatic 
calculi. 

Abnormalities  of  Position.  The  liver  may  be  upon  the  left  side  of  the 
abdomen  in  instances  of  visceral  transposition.  Not  uncommonly  is  the  organ 
tilted  forward  so  that,  although  there  is  no  increase  in  size,  the  lower  border 
may  be  palpable  below  the  costal  margin.  This  tilting  may  be  so  extreme 
that  the  vertical  diameter  of  the  organ  may  become  horizontal.  The  liver 
may  also  be  displaced  upward  by  the  pressure  of  abdominal  growths  or  by 
peritonaeal  effusions  and  downward  by  fluid  in  the  right  pleural  cavity  or  by 
the  expanded  lung  of  emphysema. 

The  movable  liver  is  a  rather  rare  condition,  which  may  be  caused  by  tight- 
lacing  and  also  may  occur  as  a  part  of  a  general  visceroptosis.  The  displace- 
ment of  the  organ  may  be  slight  only  or  so  considerable  that  the  entire  liver 
may  fall  below  the  edge  of  the  ribs  in  which  case  the  coronary  and  suspensory 
ligaments  are  so  elongated  as  to  form  a  mesohepar. 

Physical  examination  in  instances  of  marked  hepatoptosis  reveals  an  absence 
of  the  normal  liver  dulness  and  the  existence  of  a  tumor  having  the  size  and 
shape  of  the  liver  in  the  abdominal  cavity  below  the  normal  position  of  the 
organ.  The  tumor  is  usually  freely  movable  and  may  be  replaced  if  the 
patient  assumes  the  recumbent  position. 

The  symptoms  usually  observed  are  analogous  to  those  of  movable  kidney, 
namely  a  dragging  sensation  in  the  abdomen  together  with  the  nervous  mani- 
festations which  so  often  are  associated  with  nephroptosis.  In  a  considerable 
proportion  of  instances  jaundice  with  pains  resembling  those  of  hepatic  colic 
occurs. 

Treatment  consists  of  the  application  of  a  properly  fitting  belt  or  bandage 
calculated  to  hold  the  organ  in  place.  When  the  hepatoptosis  is  a  part  of  a 
general  ptosis  of  the  abdominal  viscera  the  treatment  is  that  of  the  viscer- 
optosis (see  p.  380). 


PERIHEPATITIS.  437 


PERIHEPATITIS. 


Synonym.     Capsular  Cirrhosis. 

Definition.  A  localized  peritonitis  involving  that  portion  of  the  mem- 
brane which  surrounds  the  liver. 

iEtiology.  Perihepatitis  is  observed  as  a  result  of  extension  of  some 
hepatic  inflammation  such  as  abscess;  in  association  with  a  general  peritoni- 
tis; as  an  extension  of  a  pleuritic  inflammation  through  the  diaphragm;  as  a 
result  of  traumatism;  as  a  result  of  perforation  of  the  stomach,  intestine  or  gall- 
bladder or  as  a  part  of  a  general  inflammation  {panserositis)  of  the  serous 
membranes  including  the  pleura,  pericardium  and  peritonaeum.  It  has  also 
been  considered  as  due  to  an  arterial  nephritis. 

Pathology.  Fibrinous  perihepatitis  is  characterized  by  the  exudation  of 
fibrin  upon  and  the  formation  of  adhesions  of  the  peritonaeal  covering  of  the 
liver.  These  adhesions  may,  in  the  purulent  type  of  the  inflammation, 
encapsulate  collections  of  pus  between  the  liver  and  the  diaphragm  {sub- 
diaphragmatic abscesses)  which  may  ultimately  perforate  upward  into  the 
pleural  cavity. 

In  the  chronic  form  the  inflammation  consists  of  a  marked  thickening  of 
the  entire  capsule  of  the  liver  with  consequent  contraction  and  diminution 
in  the  size  of  the  organ  which,  however,  is  itself  seldom  the  seat  of  a  cirrhosis. 
The  thickening  is  often  extreme  at  the  hilum  of  the  liver  and  there  may  be 
stenosis  of  the  blood-vessels  and  bile  ducts  at  this  point;  adhesions  to  sur- 
rounding structures  are  very  common. 

Symptoms.  These  are  often  not  in  the  least  characteristic  and  frequently 
the  condition  is  unsuspected  during  life;  pain  over  the  hepatic  region  may 
be  present.  In  some  instances  the  symptoms  are  those  of  atrophic  cirrhosis 
with  recurrent  ascites  but  no  jaundice.  Physical  examination  may  reveal 
the  presence  of  a  friction  sound  over  the  liver  or  over  the  epigastric  region 
when  there  is  marked  general  capsular  thickening.  When  there  is  a  puru- 
lent exudate  between  the  diaphragm  and  the  liver  there  is  also  a  septic  tem- 
perature with  chills  and  sweating;  the  lower  ribs  of  the  right  side  may  be 
forced  outward  and  the  physical  signs  of  pleuritic  effusion  may  be  present 
with  flatness  and  absence  of  voice,  breathing  and  vocal  fremitus  even  as  high 
as  the  angle  of  the  scapula.  Rupture  of  the  pus  cavities  may  take  place 
upward  into  the  pleura  into  the  abdominal  viscera  or  outward  through  the 
skin. 

The  diagnosis  between  suppurative  perihepatitis  and  pleuritic  effusion  is 
sometimes  difficult  but  the  early  symptoms  of  the  former  are  abdominal 
rather  than  thoracic.  The  liver  is  displaced  further  downward  in  the  former 
condition.  Aspiration  may  be  of  assistance  in  differentiation  and  it  has 
been  stated  that  the  pressure  of  the  out-flowing  fluid  is  increased  during  the 


43^       DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITON.EUM. 

descent  of  the  diaphragm  with  inspiration  in  subphrenic  abscess  while  in 
effusion  into  the  pleura  the  opposite  is  the  case. 

The  non-purulent  perihepatitis  with  localized  thickening  is  seldom  recog- 
nized during  life. 

The  prognosis  in  the  suppurative  type  is  unfavorable;  the  localized  thick- 
enings of  the  hepatic  peritonaeum  are  not  prejudicial  to  life  but  the  generalized 
perihepatitis  with  associated  thickening  of  the  other  serous  membranes  is  a 
serious  and  ultimately  fatal  condition. 

Treatment.  In  the  more  acute  instances  of  perihepatitis  before  pus- 
formation  the  patient  should  be  kept  in  bed  on  a  light  diet.  The  pain  may 
be  relieved  by  counter-irritation  in  the  form  of  hot  compresses,  mild  mustard 
poultices,  cupping  or  leeching.  The  application  of  straps  of  adhesive 
plaster  will  lessen  the  movement  and  prevent  stretching  of  the  adhesions 
but  has  the  disadvantage  that  the  interference  with  motion  tends  to  per- 
manency of  the  adhesions. 

When  pus  is  present  surgical  measures  should  be  immediately  undertaken 
with  its  evacuation  in  view. 

In  the  general  thickening  of  panserositis  with  ascites  the  treatment  is 
identical  with  that  of  hepatic  cirrhosis  with  peritonaeal  exudate  (see  p.  445). 
The  intake  of  fluids  should  be  limited,  depletion  by  purgatives  and  diuresis 
may  be  given  a  trial.  Inunctions  of  10  percent,  iodine  in  vasogen  may  be 
prescribed  in  the  hope  of  causing  absorption  of  the  peritonccal  proliferations. 
Large  accumulations  of  ascitic  fluid  necessitate  paracentesis.  Repeated 
tappings  are  sometimes  indicated.  The  treatment  of  ascites  by  means  of 
operation  will  be  discussed  in  the  section  upon  the  treatment  of  hepatic 
cirrhosis. 

ABSCESS  OF  THE  LIVER. 

Synonym.     Suppurative  Hepatitis. 

iEtiology.  Hepatic  abscess  is  in  all  probability,  in  every  instance,  the 
result  of  microbic  infection.  The  possibility  of  chemical  insult  to  the  organ, 
however,  may  be  considered. 

Infection  of  the  liver  tissue  and  subsequent  abscess  formation  may  result 
from  a  number  of  causes;  of  these  the  most  frequent  are: 

1.  Infection  with  the  amoeba  coli.  In  most  instances  of  this  form  of  the 
affection  there  is  a  preceding  tropical  amoebic  dysentery  but  amoebic  abscess 
of  the  liver  has  been  observed  in  the  absence  of  symptoms  referable  to  the 
intestine.  Amoebic  abscesses  are  usually  single,  of  considerable  size  and 
as  is  natural,  most  common  in  tropical  countries. 

2.  Pysemic  abscesses  occur  as  a  result  of  the  lodgment  in  the  blood-vessels 
of  the  liver  of  septic  emboli.     These  are  often  multiple  and  usually  of  small 


ABSCESS    OF    THE    LIVER.  439 

extent.  They  occur  in  pyaemia,  osteomyelitis,  malignant  endocarditis,  ulcer- 
ative inflammations  of  the  intestines,  pelvic  suppuration,  peritonaeal  inflam- 
mations, etc.;  when  the  primary  suppurative  process  is  in  the  area  of  the  sys- 
temic circulation  the  infection  is  brought  to  the  liver  by  the  arterial  system 
as  a  rule;  more  rarely  it  may  be  transmitted  by  means  of  the  inferior  cava 
and  the  hepatic  vein. 

3.  Foreign  bodies,  such  as  hepatic  calculi  or  parasites  may  set  up  an 
infective  cholangitis  which  may  proceed  to  abscess  formation. 

4.  Tuberculous  hepatitis  may  be  characterized  by  the  development  of 
multiple  abscesses. 

5.  The  passage  of  foreign  bodies  from  the  oesophagus,  stomach  or  duod- 
enum into  the  liver  itself,  where  an  abscess  may  result,  or  into  one  of  the  portal 
vessels,  where  an  infective  pylephlebitis  foUowed  by  an  abscess  may  take  place, 
is  a  rare  cause  of  hepatic  suppuration.  Hydatid  cysts  of  the  liver  are  subject 
to  infection  and  subsequent  abscess  formation. 

6.  Traumatism  over  the  liver  is  a  recognized  cause  of  hepatic  abscess  and 
head  injuries  may  be  followed  by  the  occurrence  of  this  lesion. 

Pathology.  Abscess  of  the  liver  may  be  single  or  multiple.  Large  abscesses 
are  most  frequently  situated  in  the  thickest  part  of  the  right  lobe,  the  cavity 
being  sometimes  so  large  as  to  involve  the  whole  of  this  structure.  The  liver 
may  be  enlarged  and,  if  the  abscess  is  near  the  surface,  a  fluctuating  swelling 
may  be  noted.  The  lining  of  the  larger  abscess  cavities  is  usually  ragged 
and  their  contents  may  be  thin  and  foetid  or  thick  and  viscid;  it  is  often  bile- 
stained.  It  often  contains  cholesterin  and  bilirubin  crystals.  The  pus  of 
the  amoebic  abscesses  usually  contains  the  amoeba  coli.  The  pus  of  echi- 
nococcus  abscesses  contains  the  characteristic  booklets. 

Pyaemic  abscesses  are  usually  small  and  multiple  but  they  do  not  often 
communicate.  They  begin  as  a  phlebitis  which  spreads  to  the  adjacent  tis- 
sues. The  liver  is  enlarged  but  its  external  appearance  may  be  unchanged;  if 
the  abscesses  are  near  the  surface  there  may  be  capsular  inflammation  and 
adhesions  to  neighboring  structures.  Superficial  abscesses  may  be  evidenced 
by  the  occurrence  of  yellowish  spots  upon  the  surface  of  the  organ.  In  marked 
instances  of  suppurative  pylephlebitis  the  liver  on  section  exhibits  a  number 
of  small  yellowish  areas,  rounded  or  branching,  from  which  pus  exudes  on 
pressure.  Careful  examination  will  reveal  the  fact  that  these  small  abscesses 
communicate  with  the  portal  vein  and  are  really  branches  of  this  vessel  in  a 
state  of  suppuration.  Involvement  of  the  entire  portal  system  may  be  observed 
and  the  infective  process  may  extend  into  the  mesenteric  or  gastric  veins. 

In  the  multiple  abscesses  of  cholangitis  the  appearance  of  the  liver  is  similar 
to  that  just  described  but  the  pus  is  in  the  bile  ducts  instead  of  in  the  branches 
of  the  portal  vein.     Gall-stones  and  suppurative  cholecystitis  are  often  present. 

Perforation  of  large  abscesses  into  the  pleura,  lung  or  any  of  t)ie  adjacent 


440         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

viscera,  into  the  peritonaeal  cavity  or  through  the  skin  externally  may  take 
place. 

Symptoms.  These  may  be  very  indefinite;  in  rare  instances  death  from 
rupture  and  general  peritonitis  may  occur  before  there  is  suspicion  of  the  true 
nature  of  the  affection. 

Elevation  of  temperature  is  quite  constant,  the  curve  being  of  the  pyaemic 
type  and  reaching  as  high,  in  some  instances,  as  105°  F.  (40.5°  C).  The  fever 
is  accompanied  by  irregular  chills  and  sweating,  the  latter  often  being  marked 
during  sleep.  Fever  may  be  slight  or  absent  in  chronic  instances  of  the 
affection.  Jaundice  in  varying  degrees  may  be  present  but  is  a  rather  incon- 
stant symptom.  There  is  pain  in  the  region  of  the  liver  or  it  may  be  referred 
to  the  shoulder  or  back.  The  patient  is  often  more  comfortable  when  lying 
on  the  right  side.  There  is  tenderness  upon  pressure  over  the  liver  especially 
at  the  margin  of  the  ribs  anteriorly.  There  may  be  a  co-existent  diarrhoea, 
especially  in  amoebic  abscess,  and  the  presence  of  the  amoebae  in  the  faeces 
is  a  great  aid  in  diagnosticating  the  condition. 

Perforation  into  any  of  the  surrounding  structures  or  through  the  skin 
may  take  place.  Rupture  into  the  lung  is  characterized  by  convulsive  cough 
with  the  expectoration  of  sputum  of  reddish  brown  tint  resembling  anchovy 
sauce,  and  the  signs  of  consoUdation  at  the  base  of  the  right  lung.  The  spu- 
tum may  contain  the  amoeba  coli. 

Physical  examination  reveals  an  increase  in  the  size  of  the  liver,  usually 
of  the  right  lobe,  which  is  enlarged  upward  rather  than  downward.  This 
enlargement  is  evidenced  by  an  extension  of  the  normal  liver  dulness  upward; 
this  is  especially  marked  in  the  mammillary  and  mid-axillary  lines.  Large 
superficial  abscesses  may  cause  a  bulging  of  the  overlying  surface  and  it  may 
even  be  possible  to  detect  fluctuation.  Adhesions  to  the  abdominal  wall 
may  take  place  and  as  a  result  of  these  fremitus  may  be  elicited.  The  com- 
pressed lung  moves  less  upon  respiration  than  normally.  In  some  instances 
of  extreme  hepatic  enlargement  the  margin  of  the  organ  may  be  palpable 
below  the  costal  margin;  its  surface  is  smooth  and  tenderness  is  often 
present. 

The  symptoms  of  the  multiple  pyaemic  or  pylephlebitic  abscesses  occur 
as  part  of  those  of  a  general  pus  infection.  The  pyaemic  temperature,  with 
its  accompanying  sweats  and  chills,  is  present  and  the  skin  may  be  jaundiced. 
There  is  pain  in  the  hepatic  region  with  tenderness  on  pressure  and  the  liver 
is  the  seat  of  a  uniform  increase  in  size. 

The  diagnosis.  Hepatic  abscess  may  be  confounded  for  a  time  with 
malarial  fever  but  the  absence  of  plasmodia  from  the  blood  and  the  inefficacy 
of  quinine  are  sufficient  to  exclude  the  latter.  When  upward  perforation 
has  taken  place  and  the  previous  symptoms  have  not  been  characteristic  the 
condition  may  be  considered  to  be  an  empyasma  or  pulmonary  abscess  but 


ABSCESS    or    THE    LIVER.  441 

the  presence  of  the  anchovy  sauce  sputum  and  of  amoebae  renders  the  diagnosis 
simple. 

Infected  echinococcus  cyst  may  be  diagnosticated  as  abscess  but  its  character 
is  hardly  recognizable  unless  booklets  are  found  in  the  aspirated  pus.  The 
employment  of  the  exploring  needle  is  to  be  advised  in  suspected  abscess  of 
all  varieties  but  a  failure  to  withdraw  pus  does  not  exclude  the  possibility  of 
its  presence.  The  needle  should  be  of  moderate  calibre  and  the  operation 
should  be  performed  under  general  anaesthesia.  The  usual  points  of  puncture 
are  over  the  point  of  maximum  dulness,  in  the  seventh  interspace  in  the  an- 
terior axillary  line  or  in  the  seventh  space  in  the  mid-axillary  line. 

Hepatic  intermittent  fever  due  to  the  presence  of  calculi  is  associated  with 
a  history  of  biliary  colic  and  the  presence  of  more  extreme  icterus;  in  other 
respects,  such  as  in  its  temperature  curve,  chills,  sweating  and  liver  tenderness, 
it  may  resemble  the  more  serious  condition  of  abscess. 

Leucocytosis  is  usually  marked  in  abscesses  of  the  liver  of  the  pyaemic 
variety;  it  is  likely  to  be  absent  in  those  due  to  the  presence  of  the  amoeba 
coli. 

The  prognosis,  since  early  operation  has  become  the  preferred  mode  of 
treatment,  seems  to  be  more  favorable  than  previously.  In  any  case,  however, 
the  condition  is  a  very  serious  one  and  the  probability  of  a  fatal  outcome  is 
great. 

Treatment.  If  the  patient  is  seen  early  he  should  be  kept  in  bed  upon  a 
fluid  diet  and  an  ice  bag  should  be  applied  over  the  liver;  cupping  is  advised 
and  the  application  of  a  number  of  leeches  to  the  hepatic  region  and  about 
the  anus,  in  order  to  relieve  the  congestion  of  the  portal  system,  may  be  em- 
ployed. The  bowels  should  be  kept  freely  open  by  the  administration  of  mild 
laxatives  and  ammonium  chloride  in  20  grain  (1.33)  doses  3  times  daily  may 
be  given  empirically.  In  the  future  we  may  be  able  to  treat  the  condition 
by  means  of  the  hypodermatic  injection  of  a  bactericidal  serum,  examination 
of  the  patient's  blood  revealing  the  character  of  the  causative  micro-organism 
and  the  type  of  serum  indicated. 

As  soon  as  the  presence  of  an  abscess  is  determined  surgical  measures 
should  be  undertaken.  These  consist  of  various  procedures  such  as  aspiration, 
which  is  most  likely  to  be  successful  in  tropical  abscesses;  puncture  with 
drainage,  a  large  canula  being  employed  and  left  in  situ — later  it  may  be 
replaced  by  a  drainage  tube  of  rubber;  and  free  opening  with  the  knife.  The 
interior  of  the  cavity  should  be  thoroughly  investigated  and  neighboring 
abscesses,  if  present,  also  evacuated.  After  incision  free  drainage  should  be 
provided.  Rupture  into  the  peritonaeum,  pleura,  lung,  pelvis  of  the  kidney 
or  pericardium  necessitates  immediate  surgical  interference.  In  rupture 
into  the  intestine  without  peritonaeal  involvement,  operation  need  not  be 
undertaken  unless  the  contents  of  the  gut  enters  the  abscess  cavity  and  pro- 


442         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM, 

duces  a  gangrenous  process;  here  external  opening  and  drainage  are  indi- 
cated. 

During  convalescence  the  patient  should  seek  a  change  of  climate,  either 
at  the  seashore  or  the  mountains,  and  tonics  with  abundant  nourishing  food 
should  be  prescribed. 

Multiple  pysemic  and  pylephlebitic  abscesses  are  fatal,  usually  without 
exception,  and  unless  signs  of  localization  become  evident,  radical  measures 
are  hardly  advisable,  the  treatment  being  that  of  ordinary  pyaemia. 


CIRRHOSIS  OF  THE  LIVER. 

Synonyms.  Interstitial  Hepatitis;  Gin-drinker's  Liver;  Hob-nail  Liver; 
Sclerosis  of  the  Liver. 

Definition.  A  chronic  inflammation  of  the  connective  tissue  framework 
of  the  liver  resulting  first  in  an  hypertrophy  of  the  organ  and  later,  because 
of  the  tendency  of  the  newly  produced  connective  tissue  to  contract,  in  a 
diminution  in  its  size  and  a  consequent  compression  of  its  parenchymatous 
structure. 

.etiology.  The  causation  of  this  disease  has  been  in  too  great  a  degree 
attributed  to  the  abuse  of  alcohol.  While  there  is  no  doubt  that  alcoholic 
beverages  exercise  a  certain  amount  of  influence  in  its  aetiology,  it  is  probably 
true  that  this  influence  is  rather  the  result  of  their  adulteration  with  deleterious 
substances  and  the  fact  that  many  wines  are  to-day  artificially  made  from  vine- 
gar, logwood,  etc.,  mixed  with  alcohol,  than  due  to  the  alcohol  itself.  It  is 
also  true  that  hepatic  cirrhosis  may  be  artificially  produced  in  the  lower 
animals  in  a  short  time,  without  the  use  of  alcohol,  by  the  administration 
of  lactic,  butyric,  acetic  and  valerianic  acids.  Of  these  substances,  all  except 
the  last  may,  in  the  human  organism,  result  from  digestive  disorders,  which 
are  frequently  caused  by  the  ingestion  of  sophisticated  wines,  such  as  those 
mentioned  above,  beers  adulterated  with  picrotoxin,  aloes,  glucose,  etc.  Con- 
sequently the  tendency  to  take  a  broader  view  of  the  disease  should  be  encour- 
aged and  the  cause  should  be  sought  in  the  alimentary  canal. 

Syphilis,  particularly  of  the  congenital  type,  is  not  an  infrequent  cause  of 
cirrhosis,  especially  in  children,  and  chronic  malarial  poisoning  must  be  con- 
sidered as  a  factor  in  the  aetiology  of  this  condition. 

Trauma  cannot  be  considered  a  true  cause  of  hepatic  cirrhosis  but  it  may 
result  in  a  localized  perihepatitis  beneath  which  a  patch  of  interstitial  cica- 
tricial tissue  may  exist.     This  however  never  spreads  through  the  organ. 

The  disease  is  usually  seen  in  adults  and  in  males  more  often  than  in  females. 
It  does,  however,  occur  in  children,  in  whom  it  may  or  may  not  be  the  result 
of  congenital  syphilis. 


CIRRHOSIS    OF    THE    LIVER.  443 

Pathology.  The  liver* after  death  may  be  found  to  be  either  enlarged,  of 
normal  size,  or  contracted.  Its  surface  may  be  smooth  or  nodular.  On 
section  it  may  be  yellowish-red — especially  in  -alcoholic  patients — or  yellow 
as  a  result  of  staining  with  bile  pigments. 

The  chronic  productive  inflammation  results  in  an  increase  in  the  connec- 
tive tissue  stroma  of  the  organ.  This  new  tissue  may  surround  groups  of 
the  liver  acini  or  may  be  diffusely  distributed  among  the  liver  cells,  which  are 
constricted  by  it  and  it  may  be  the  seat  of  a  fatty  degeneration.  The  flow  of 
blood  through  the  organ  is  obstructed  by  the  new  growth  of  tissue  and  as  a 
result  of  this  the  spleen  becomes  enlarged,  there  may  be  ascites  and  the  lining 
of  the  stomach  and  intestines  becomes  congested.  The  increase  of  the  stroma 
in  the  liver  also  may  obliterate  the  small  bile  ducts  and  the  large  ones  frequently 
are  the  seat  of  a  catarrhal  inflammation. 

In  many  patients  there  is  a  general  accompanying  increase  in  the  connec- 
tive tissues  throughout  the  body  resulting  in  arteriosclerosis,  fibromyocarditis, 
nephritis,  etc. 

Symptoms.  The  symptoms  of  hepatic  cirrhosis  may  be  classed  as 
follows : 

1.  Those  due  to  the  co-existent  inflammation  of  the  gastric  mucosa. 

2.  Those  due  to  the  interference  with  the  secretion  of  bile. 

3.  Those  due  to  the  interference  with  the  portal  circulation. 

4.  Those  due  to  the  accompanying  connective  tissue  inflammations  in 
the  heart,  arteries,  kidneys  and  lungs. 

The  gastric  symptoms  may  by  several  years  antedate  those  of  the  cirrhosis 
itself,  and  usually  are  those  of  a  chronic  gastritis,  vdth  nausea,  and  vomiting — 
which  may  often  be  the  early  morning  "  water  brash  "  of  alcoholic  gastritis — 
eructations  and  constipation.  The  gastric  symptoms  are  more  pronounced 
in  patients  with  an  enlarged  liver. 

Jaundice  of  greater  or  less  degree  is  a  common  symptom  and  occurs  more 
frequently  in  the  presence  of  an  enlarged  liver  than  in  the  atrophic  form  of 
the  inflammation.  With  this  symptom  the  urine  contains  bile  and  the  faeces 
are  more  or  less  clay-colored.  In  certain  patients  a  rapidly  fatal  form  of 
jaundice  occurs  with  emaciation,  fever,  and  marked  gastric  and  cerebral  symp- 
toms.    This  variety  results  in  death  within  a  short  period. 

Haemorrhages  from  the  oesophagus,  stomach,  intestines  and  more  rarely 
from  the  uterus,  nose,  kidneys  and  bladder,  are  symptoms  referable  to  the 
obstruction  of  the  portal  circulation  by  the  new  growth  of  connective  tissue. 
They  may  be  large  and  at  times  alarming  but  only  seldom  result  fatally, 
their  usual  effect  being  beneficent  since  they  relieve  the  portal  congestion. 

Dilatation  of  the  superficial  veins  of  the  epigastrium  and  lower  part  of  the 
chest  is  due  to  the  damming  back  of  the  blood  in  the  portal  into  the  systemic 
circulation.     This  in  extreme  instances  may  result  in  the  formation  of  the 


444        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

caput  MeduscB,  the  name  given  to  the  plexus  of  largely  dilated  veins  about 
the  umbilicus. 

Ascites  of  greater  or  less  degree  is  a  common  symptom  of  cirrhosis  with  a 
contracted  liver.  The  abdominal  fluid  results  from  the  portal  obstruction  and 
varies  in  quantity  from  a  pint  (J  litre)  or  two  to  an  amount  so  large  that  the 
abdomen  is  distended  to  such  an  extent'  that  there  is  protrusion  of  the  umbil- 
icus. Hydrothorax  may  occur  and  oedema  olF  the  legs  may  result  from  the 
pressure  exerted  by  the  ascitic  fluid  upon  the  veins  returning  the  blood  from 
the  lower  limbs.  These  symptoms  are  more  frequently  seen  in  the  atrophic 
variety  of  the  disease. 

Splenic  enlargement  exists  in  a  considerable  number  of  patients,  especially 
when  the  liver  is  small;  often  the  presence  of  ascites  makes  examination  of 
the  spleen,  as  well  as  of  the  liver,  so  unsatisfactory  that  it  is  necessary  to  wait 
until  paracentesis  has  been  performed. 

The  enlarged  liver  may  be  tender  and  is  usually  smooth  of  surface,  while 
the  atrophic  organ  may  be  nodular. 

The  blood  usually  shows  a  considerable  diminution  in  both  red  cells  and 
haemoglobin. 

The  urine  of  the  hypertrophic  liver  is  usually  of  normal  specific  gravity 
and  is  not  likely  to  contain  albumin.  Bile  pigment  is  frequently  present. 
The  urea  content  is  not  usually  diminished. 

In  the  urine  of  atrophic  instances,  bile  pigment  is  seldom  present,  the  specific 
gravity  is  low,  albumin  and  casts  may  exist,  the  urea  is  usually  diminished, 
and  in  the  later  stages  of  the  disease  blood  may  be  found. 

The  symptoms  of  the  concomitant  connective  tissue  inflammations  of  the 
lungs,  heart,  arteries,  etc.,  are  those  of  these  conditions  when  they  occur  sepa- 
rately. 

Rise  in  temperature  is  not  a  feature  of  the  disease  but  may  occur  when 
death  is  about  to  take  place. 

Physical  Signs.  These  differ  greatly  in  different  patients  and  with  the  stage 
of  the  disease.  On  inspection  the  patient's  skin  and  mucous  membranes 
are  usually  seen  to  be  pale;  jaundice  of  the  skin  may  be  present  or  there  may 
be  merely  the  sub-icteroid  hue  and  slight  yellowness  of  the  whites  of  the  eyes. 
There  may  be  oedema  of  the  feet  or  general  anasarca.  When  much  intra- 
abdominal fluid  is  present  the  abdomen  is  likely  to  be  prominent  and  tense; 
its  superficial  veins  are  dilated  and  at  times  the  varicose  condition  of  these 
structures  known  as  the  caput  Medusa  is  present.  Palpation  may  reveal 
a  large,  small  or  normal  sized  liver  with  a  rough  or  smooth  surface.  The 
spleen  may  or  may  not  be  palpable.  Percussion  may  give  us  additional 
information  as  to  the  size  of  the  liver  and  spleen  and  when  ascites  is  present 
the  note,  while  the  patient  lies  upon  his  back,  will  be  flat  over  the  flanks, 
while  that  over  the  umbilical  region,  unless  the  abdominal  cavity  is  entirely 


CIRRHOSIS    OF    THE    LIVER.  445 

filled  with  fluid,  will  be  tympanitic.  Upon  turning  the  patient's  body  to 
its  side  the  flatness  in  the  flanks  will  be  found  movable  if  the  fluid  does  not 
wholly  fill  the  abdomen. 

The  physical  signs  of  the  accompanying  heart,  arterial,  kidney  and  pul- 
monary involvement  wiU  likewise  be  present  (see  the  sections  upon  the 
diseases  of  these  structures),  as  well  as  those  due  to  displacement  of  the  ab- 
dominal viscera  by  the  ascitic  fluid. 

The  prognosis.  Cirrhosis  of  the  liver  is  a  serious,  though  by  no  means 
always  fatal  condition.  In  certain  instances  the  progress  of  the  inflamma- 
tion may  cease  and  the  patient  may  die  of  some  other  disease.  Its  course  is 
usually  chronic,  lasting  a  year  or  two,  although  instances  proving  rapidly 
fatal  have  been  reported.  The  hypertrophic  form  seems  more  rapid  in  its 
evolution  than  does  the  atrophic. 

Treatment.  The  treatment  of  this  condition  may  be  separated  into  the 
following  heads: 

1.  The  diminution  of  the  excessive  connective  tissue  in  the  liver. 

2.  The  treatment  of  the  symptoms  of  the  disease  as  they  arise. 

3.  The  prevention  of  further  connective  tissue  change  in  the  liver  and 
consequent  destruction  of  its  parenchyma. 

Toward  accomplishing  the  first  of  these  objects  it  is  hardly  probable  that 
much  can  be  done.  The  absorption  of  connective  tissue  grovrth,  especially 
when  syphilitic  in  origin,  should  always  be  attempted  by  the  use  of  some  form 
of  iodine.  Consequently  this  drug  should  be  given  tentatively  whenever 
specific  disease  is  even  suspected.  To  achieve  any  effect  its  administration 
should  be  continued  for  a  very  considerable  period.  In  all  instances  it  is 
wise  to  give  this  agent  a  thorough  trial.  In  the  opinion  of  the  author  the 
preferable  method  of  administering  iodine  is  in  the  official  syrupus  acidi 
hydriodici  of  the  pharmacopoeia.  It  should  be  given  in  doses  of  one  drachm 
(4.0)  well  diluted  J  hour  before  each  meal,  and  is  preferable  to  potassium 
iodide,  being  less  likely  to  cause  iodism. 

The  Treatment  0}  Symptoms.  Ascites.  This  symptom  may  be  treated 
by,  a.  Depletion  by  means  of  diuretics  and  purgatives :  Free  diuresis  may 
be  produced  and  moderate  ascites  diminished  by  the  administration  of  the 
Guy's  diuretic  pill — calomel,  powdered  digitalis,  powdered  squill,  aa  i  grain 
(0.065) — with  the  addition  of  J  grain  (0.016)  of  extract  of  hyoscyamus  to  pre- 
vent griping.  One  of  these  pills  should  be  given  3  times  a  day  for  one  week, 
then  omitted  for  a  week,  repeated  for  a  week  and  so  on.  Numerous  other 
diuretic  drugs  may  be  employed  in  this  connection.  Of  the  potassium  salts 
the  acetate,  bitartrate,  or  citrate  may  be  employed;  the  preference  is  in  favor 
of  the  first.  It  may  be  given  in  doses  of  20  grains  (1.33)  3  times  a  day.  Theo- 
brmione  has  given  different  results  in  the  hands  of  different  observers  but 
the  consensus  of  opinion  that  it  is  inferior  in  ascites  due  to  hepatic  cirrhosis 


446         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

to  a  number  of  other  diuretics.  Small  doses  of  calomel  frequently  repeated 
increase  the  excretion  of  urine.  Citrated  cafieine  in  doses  of  from  2  to  5 
grains  (0.13  to  0.33)  may  be  employed.  The  fluidextract  of  apocynum  can- 
nabinum  is  an  active  diuretic  in  ascites,  but  should  be  given  vi^ith  care  on 
account  of  its  tendency  to  disturb  the  digestion.  Its  dose  is  from  10  to  20 
drops  (0.66  to  1.33).  The  resin  of  copaiba  increases  the  secretion  of  the 
kidneys  but  on  account  of  its  liability  to  cause  gastric  irritation  should  be 
given  in  capsules  coated  with  keratin,  10  to  20  grains  (0.66  to  1.33)  in  each 
capsule.  The  fluid  extract  of  asparagus  in  drachm  (4.0)  doses  is  a  diuretic 
drug  which  may  be  tried. 

Depletion  by  means  of  purgatives  may  be  used  as  an  adjunct  to  that  by 
means  of  diuresis  and  numerous  drugs  of  this  class  may  be  employed.  Epsom 
salts,  2  ounces  (60.0),  dissolved  in  4  ounces  (120.0)  of  boiling  water  and 
allowed  to  cool,  if  given  in  the  morning  before  breakfast,  no  liquid  having  been 
drunk  since  supper  the  night  before,  will  produce  5  to  6  watery  stools  during 
the  day.  This  mixture  given  twice  a  week  will  often  ward  off  tapping  for 
some  time.  Sodium  phosphate  is  also  an  excellent  purge  and  an  hepatic 
stimulant  as  well;  it  may  be  given  in  doses  of  ^  to  2  drachms  (2.0  to  8.0)  at 
varying  intervals  according  to  the  effect  produced.  Laxative  mineral  waters 
or  their  artificial  salts  may  also  be  employed  in  this  connection.  Vegetable 
cathartics  such  as  cascara  sagrada,  rhubarb,  aloes  and  jalap  may  be  used 
alternating  with  the  salines.  It  is  unwise  to  endeavor  to  remove  ascites  by 
marked  purgation  by  means  of  the  stronger  hydrogogues  for  the  attempt  may 
be  made  at  the  sacrifice  of  the  patient's  strength. 

Diminution  of  the  ingested  fluids  in  ascites  is  hardly  to  be  advised  since, 
while  it  may  reduce  the  quantity  of  the  transudate,  this  good  is  more  than 
counter-balanced  by  the  resulting  diminution  in  the  urine  and  tendency  to 
constipation. 

The  treatment  of  dropsical  conditions  by  the  elimination  from  the  diet 
of  chloride  containing  substances  is  receiving  much  attention  and  for  it  great 
claims  are  made.  As  a  tentative  measure  it  can  do  no  harm  in  cirrhotic 
ascites  and  future  research  may  throw  more  light  upon  the  subject.  For 
a  consideration  of  the  dechloridation  treatment  the  reader  is  referred  to  the 
section  upon  chronic  nepliritis. 

b.  Abdominal  paracentesis  or  tapping.  At  the  present  time  it  is  considered 
wise  to  tap  the  abdominal  cavity  as  soon  as  the  fluid  is  of  sufficient  quantity 
to  annoy  the  patient;  the  old  statement  that  a  patient  seldom  survived  two 
tappings  no  longer  holds,  perhaps  because  of  the  present  lessened  danger 
of  infection  and  the  fact  that  the  procedure  is  not  now  employed  as  a  last 
resort.  Accordingly,  paracentesis  should  be  performed  as  soon  as  the  fluid 
causes  any  mechanical  interference  with  the  functions  of  the  abdominal  or 
thoracic  viscera.     Complaint  of  discomfort  on  the  part  of  the  patient  is  an 


CIRRHOSIS    OF    THE    LIVER.  447 

indication  for  the  operation  as  well  as  is  a  diminution  of  urine  due  to  pressure 
upon  the  vessels  of  the  kidneys  by  the  fluid,  interference  with  digestion  or 
respiration  due  to  the  same  cause,  pulmonary  congestion,  as  evidenced  by  the 
presence  of  rales  at  the  bases  of  the  lungs  posteriorly,  etc.  In  instances  of 
ascites  with  haematemesis  due  to  venous  congestion  in  the  mucous  membrane 
lining  the  stomach  the  procedure  is  also  indicated. 

Technique  of  Abdominal  Paracentesis.  The  only  apparatus  needed  is  a 
trocar  and  canula  of  rather  small  calibre  (^^  to  J  in.)  and  of  sufficient  length 
to  penetrate  the  abdominal  wall  of  the  patient  in  hand,  and  a  few  feet  of 
rubber  tubing  to  be  attached  to  the  canula,  after  the  puncture,  to  lead  the 
fluid  to  a  vessel  of  sufficient  size  which  is  placed  upon  the  floor. 

The  patient's  bladder  should  be  emptied,  and  the  site  of  the  intended 
puncture  sterilized  by  scrubbing  with  soap  and  hot  water,  alcohol,  aether  and 
1-5,000  mercury  bichloride  solution.  The  usual  site  is  in  the  mid-line  of  the 
anterior  aspect  of  the  abdomen  about  equidistant  between  the  os  pubis  and 
the  umbilicus;  the  situation  chosen  must  be  flat  upon  percussion.  If  no  fluid 
is  obtained  at  the  situation  above  mentioned  the  puncture  may  be  made 
at  about  the  same  level  either  to  the  right  or  left.  The  right  iliac  fossa  should 
be  carefully  avoided  because  of  the  possibility  of  puncturing  the  coecum  in 
this  vicinity. 

The  trocar  and  canula  and  the  operator's  hands  having  been  properly 
sterilized  and  the  site  of  the  intended  puncture  anaesthetized  by  the  application 
of  the  ethyl  chloride  spray  or  the  subcutaneous  injection  of  a  few  drops  of  a 
4  percent,  solution  of  cocaine  hydrochloride,  the  puncture  is  made,  the  trocar 
removed  and  the  rubber  tubing  attached.  The  patient  may  remain  in  a  sitting 
or  semi-reclining  position  during  the  procedure  and,  as  the  fluid  is  drained, 
an  abdominal  binder,  which  is  tightened  from  time  to  time,  to  prevent  sudden 
intestinal  distention,  is  applied.  Should  the  fluid  stop  flowing  before  the 
abdominal  cavity  is  empty  the  canula  may  be  cleared  by  passing  the  trocar 
through  it  to  dislodge  any  impediment.  When  sufficient  fluid  has  been 
removed  the  canula  should  be  withdrawn  and  the  puncture  dressed  by  the 
application  of  a  bit  of  sterile  gauze  or  cotton  held  in  place  by  adhesive  plaster 
or  collodium.  The  patient  should  wear  the  abdominal  bandage  for  several 
days  following  the  operation.  When  a  trocar  of  small  calibre  is  used  there 
is  little  danger  that  the  puncture  will  not  heal  without  leakage.  The  consti- 
pation which  may  follow  tapping  of  the  abdominal  cavity  and  the  possible 
tympanites  may  be  relieved  by  saline  laxatives. 

c.  The  treatment  of  ascites  by  operation  with  the  view  of  establishing  a 
collateral  circulation  between  the  systemic  and  portal  veins,  the  so-called 
Talma's  operation,  has  been  much  discussed  but  its  results  from  a  curative 
standpoint  are  not  all  that  could  be  desired,  which  fact  in  the  opinion  of  some 
observers,  is  due  to  the  procedure  being  usually  employed  as  a  measure  of 


448         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

last  resort.  It  is  possible  that  the  results  might  be  more  favorable  were  the 
operation  undertaken  early  in  the  disease.  For  the  description  of  the  opera- 
tive technique  of  omental  anastomosis  and  epiplopexy  the  reader  is  referred 
to  works  upon  abdominal  surgery. 

Hcematemesis.  The  treatment  of  this  distressing  symptom  of  cirrhosis 
of  the  liver  differs  little  from  that  of  the  haeraatemesis  of  gastric  ulcer,  see  p. 
365.  The  patient  should  receive  no  food  by  the  mouth  for  three  or  four 
days  following  the  haemorrhage  and  during  this  period  food  may  be  admin- 
istered per  rectum.  The  first  food  allowed  should  be  in  fluid  form  and  may 
consist  of  milk,  gruels,  and  broths,  if  possible  partly  predigested  by  peptoniza- 
tion. Gradually  the  patient  should  be  brought  back  to  solid  diet  (see  feeding 
in  gastric  ulcer,  p.  366),  and  after  about  10  days  he  may  be  allowed  to  leave 
his  bed.  The  after  treatment  consists  in  a  regulation  of  the  diet,  only  easily 
digested  and  non-irritating  foods  being  allowed,  and  the  administration  of 
tonics.  The  patient  should  be  advised  to  conduct  his  habits  and  mode  of 
life  in  accordance  with  hygienic  principles. 

Hemorrhage  evidenced  by  the  appearance  of  blood  in  the  stools.  Blood  so 
changed  by  the  fluids  of  digestion  that  it  presents  a  tarry  appearance  may  be 
voided  with  the  fasces  even  when  there  has  been  no  vomiting  of  blood.  After 
such  haemorrhage  the  patient  must  remain  quiet  for  a  number  of  days  and 
his  feeding  should  be  carefuUy  conducted.  Otherwise  the  treatment  consists 
in  meeting  the  indications  as  they  arise. 

The  management  of  rectal  haemorrhage  due  to  the  presence  of  haemorrhoids 
consists  in  treatment  of  this  complication  in  accordance  with  ordinary  methods, 
(see  the  section  on  haemorrhoids.) 

The  treatment  of  concomitant  digestive  disturbances.  Alcoholic  drinks 
are  contra-indicated  and  the  diet  should  be  so  regulated  as  to  prevent  the 
formation  in  the  digestive  tract  of  such  products  of  fermentation  as  lactic, 
acetic  and  butyric  acids.  The  accompanying  chronic  gastritis  with  the 
excessive  production  of  mucus  which  is  of  frequent  occurrence  may  be 
relieved  by  the  drinking  of  a  glass  of  hot  water  before  each  meal,  which  tends 
to  dissolve  the  mucus  from  the  wall  of  the  stomach,  or  by  gastric  lavage. 
Fermentation  may  also  be  relieved  by  the  administration  of  drugs  of  the 
class  of  internal  antiseptics  such  as  phenyl  salicylate,  resorcinol,  sodium  phenol- 
sulphonate  and  the  bismuth  salts,  particularly  the  naphtholate.  Small  re- 
peated doses  of  calomel  are  useful  in  this  connection,  gr.  -^-^  (0.006).  The 
use  of  this  drug  will  also  tend  to  prevent  constipation.  The  bowels  should 
not  be  allowed  to  become  constipated  for  this  condition  favors  the  production 
of  the  toxic  substances  above  mentioned.  Constipation  may  be  prevented 
by  the  moderate  use  of  salines  such  as  sodium  phosphate  or  sulphate,  the 
laxative  mineral  waters,  etc.  The  drinking  of  plenty  of  ordinary  water  is 
to  be  recommended. 


CIRRHOSIS    OF    THE    LIVER.  449 

Atonic  conditions  of  the  stomach  call  for  the  administration  of  small  doses 
of  strychnine,  y^o  to  -gV  of  a  grain  (0.0006  to  o.ooi).  The  use  of  pepsin 
and  other  artificial  digestants,  in  the  opinion  of  the  most  advanced  observers, 
is  unnecessary. 

The  administration  of  drugs  prepared  with  alcohol  is  to  be  avoided  in  so 
far  as  possible. 

The  ^prevention  of  further  connective  tissue  growth  in  the  liver  is  to  be  brought 
about  by  attention  to  the  gastric  condition,  the  treatment  of  which  has  been 
dealt  with  above,  and  by  regulation  of  the  diet  and  mode  of  life.  Alcohol 
should  be  forbidden  and  the  patient  should  become  a  total  abstainer.  Tobacco 
should  be  used  in  moderation  only,  if  at  all.  The  interdiction  of  alcohol, 
of  course,  does  not  apply  to  those  late  stages  of  the  disease  where  its  use  as 
a  stimulant  is  necessary.  Some  patients,  no  matter  what  is  said  by  the  phy- 
sician, will  insist  upon  taking  a  certain  amount  of  alcohol;  such  should  be 
directed  to  take  it  largely  diluted  and  upon  a  fvdl  stomach. 

Diet.  Certain  observers  consider  an  exclusive  milk  diet  the  ideal  in  cir- 
rhosis of  the  liver,  which  it  no  doubt  is,  but  it  will  be  found  difficult  in  private 
practice  for  obvious  reasons  to  enforce  so  restricted  a  regime.  Certain  patients 
either  cannot  or  think  that  they  cannot  take  milk,  others  refuse  to  undertake 
such  a  rigid  diet.  Where  milk  is  not  well  borne  it  may  be  taken  in  the  form 
of  skim  milk — which  reduces  its  fat  content — diluted  with  carbonic,  Vichy 
or  other  mineral  water.  Kumyss  or  matzoon  may  be  agreeable  temporary 
substitutes  for  milk,  but  the  former  possesses  the  great  disadvantage  that  it 
contains  alcohol.  The  quantity  of  milk  necessary  is  from  2  to  3  quarts 
(litres)  every  24  hours,  and  it  is  best  borne  when  taken  in  small  quantities 
at  a  time.  At  times  it  may  be  advantageous,  especially  when  digestion  is 
impaired,  to  partially  predigest  the  milk  by  peptonization.  Various  semi-soHds 
such  as  gruels,  junket,  etc.,  which  have  milk  as  their  basis,  often  furnish  a 
pleasing  variation  to  the  routine.  At  the  beginning  of  treatment  a  milk  diet 
should  usually  be  prescribed,  to  be  followed,  as  the  patient  improves,  by  a 
gradual  return  to  solids.  The  easily  digested  cereals,  soft-boiled  eggs,  vegeta- 
ble puree  soups,  may  be  given  first,  to  be  followed  by  a  more  liberal  diet.  All 
highly  seasoned  or  spiced  foods  are  ta  be  forbidden,  but  the  patient  may  be 
allowed  fish  or  meat  at  one  meal  during  the  day  and  a  moderate  amount  of 
carbohydrate  food  in  the  form  of  green  vegetables  and  stewed  fruit.  A 
moderate  amount  of  white  bread  either  toasted  or  not  may  be  permitted. 
Fats  must  be  restricted  since  when  digestion  is  impaired  they  are  very  prone 
to  give  rise  to  the  fermentation  products  which  are  such  a  considerable  factor 
in  the  causation  of  hepatic  cirrhosis.  Too  much  starchy  food  must  not  be  given 
on  account  of  the  likelihood  of  consequent  gastric  and  intestinal  fermentation.. 

With  regard  to  beverages,  cocoa  made  with  milk,  tea  and  coffee,  with  the 
addition  of  plenty  of  milk,  may  be  allowed. 
29 


450         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

The  patient's  mode  of  life  should  be  modeled  on  hygienic  lines  of  which 
regularity  is  the  key-note.  Regular  hours  for  eating,  exercise  and  sleep  should 
be  insisted  upon.  With  regard  to  exercise  a  moderate  amount  of  bicycling, 
walking  or  golf  may  be  suggested. 

Water  cures  at  various  springs  and  baths  may  often  be  taken  in  the  early 
stages  of  the  disease  with  good  results.  In  the  United  States,  Saratoga  may 
be  recommended  and  the  continental  spas  at  Carlsbad,  Vichy,  Marienbad 
and  Homburg  may  be  mentioned  in  this  connection.  It  is  quite  as  likely 
that  the  regular  mode  of  life  prescribed  at  places  of  this  sort  will  do  as  much 
for  the  patient  as  will  the  bathing  in  or  drinking  of  the  waters. 

Massage  and  passive  muscular  exercises  in  patients  too  weak  to  take 
active  exercise  are  useful  adjuncts  to  treatment,  and  abdominal  massage  is 
important  in  relieving  the  common  symptom  of  constipation. 

Drugs,  other  than  those  hitherto  mentioned,  have  been  employed  in  consid- 
erable number  with  the  object  of  combating  the  disease.  Claims  have  been 
made  for  ammonium  chloride,  iodoform  and  nitrohydrochloric  acid.  The 
administration  of  iodoform  has  been  undertaken  on  account  of  its  content 
of  iodine  but  potassium  iodide  is  quite  as  effective  and  better  tolerated.  Nitro- 
hydrochloric acid  may  be  given  in  as  large  doses  as  the  patient  will  tolerate. 

Organotherapy  by  the  administration  of  macerated  pig's  liver  and  by 
hypodermatic  injection  of  liver  extract  has  been  attempted  and  good  results 
have  been  reported  by  a  number  of  French  observers.  Apparently  this  form 
of  treatment  does  no  harm  other  than  causing  loosene'ss  of  the  bowels,  and 
future  experimentation  may  throw  more  light  upon  this  interesting  subject. 

THE  FATTY  LIVER. 

.Etiology.  Fatty  infiltration  is  to  some  extent  present  in  the  normal  liver, 
tiny  droplets  of  oil  being  always  contained  in  the  hepatic  cells.  In  such  con- 
ditions as  obesity  and  chronic  alcoholism  the  liver  cells  contain  more  than  their 
normal  amount  of  fat,  the  excessive  quantity  ingested  or  produced  by 
metabolism  being  stored  in  this  situation.  In  cachectic  states,  such  as  chronic 
tuberculosis,  extreme  anaemia,  etc.,  there  is  an  interference  with  oxidation 
and  the  ingested  fat  accumulates  in  the  liver. 

A  third  type  of  the  fatty  liver  is  that  which  occurs  in  phosphorus  poisoning 
and  is  analogous  to  the  change  which  takes  place  in  acute  yellow  atrophy. 
The  substance  of  the  cell  is  converted  into  fat — and  perhaps  other  substances 
— and  necrosis  follows.  This  is  a  more  serious  condition  than  the  fatty  infil- 
tration observed  in  obesity  and  cachectic  states. 

Pathology.  The  fatty  liver  is  uniformly  one  of  the  largest  met  as  a  result 
of  pathological  change.  Its  consistency  is  soft  and  its  surface  smooth;  its 
color  is  light  and  in  the  later  stages  yellowish.     Its  cut  surface  is  dry  and 


*      THE    AMYLOID    LIVER.  45 1 

greasy.  The  increase  in  fat  resiilts  in  such  a  decrease  in  the  specific  gravity 
of  the  organ  that  it  floats  in  water. 

Symptoms.  These  are  not  characteristic.  Jaundice  is  absent  and  although 
the  fasces  may  be  light  in  color  there  is  little  interference  with  the  formation 
of  bile.  There  is  no  ascites  and  the  spleen  is  not  increased  in  size.  In  obese 
patients  the  hepatic  enlargement  may  be  impossible  of  demonstration  but  in 
emaciated  subjects  the  enlarged  organ  is  easily  palpated.  Its  consistency 
is  inclined  to  be  soft  and  its  surface  smooth. 

The  diagnosis  of  the  fatty  liver  is  usually  not  difl&cult.  It  may  be  differ- 
entiated from  the  amyloid  liver  by  its  less  fu-m  consistency,  the  absence  of 
splenic  enlargement  and  albuminuria  (see  also  the  diagnosis  of  cancer  of  the 
liver,  p.  458). 

The  prognosis  is  that  of  the  associated  disease.  Patients  with  fatty  liver 
bear  surgical  operations  poorly  and  often  fall  an  easy  prey  to  intercurrent 
disease,  especially  pneumonia. 

Treatment.  The  treatment  of  the  affection  is  that  of  the  primary  cause, 
such  as  tuberculosis  or  obesity.  In  the  former  condition  a  limitation  of  the 
ingested  fats,  codliver  oil,  etc.,  has  been  suggested.  In  the  instances  of 
fatty  degeneration  resembling  acute  yellow  atrophy  the  treatment  is  that 
of  this  disease. 

THE  AMYLOID  LIVER. 

Synonyms.     Waxy,  Lardaceous  or  Albuminoid  Liver. 

Definition.  An  affection  of  the  liver  characterized  by  various  degrees  of 
infiltration  of  the  substance  of  the  organ  by  amyloid  material. 

.Etiology.  Amyloid  liver  occurs  as  a  part  of  the  generalized  waxy  degen- 
eration of  the  viscera  which  is  associated  with  cachectic  states,  particularly 
those  characterized  by  prolonged  suppuration.  It  is  especially  common  in 
tuberculous  bone  disease  but  is  less  frequent  with  pulmonary  tuberculosis. 
Of  other  causes  tertiary  syphilis  is  important  and  the  condition  is  also  observed 
in  cancerous  cachexia,  rickets  and  in  protracted  convalescence  from  the  acute 
infectious  diseases. 

Pathology.  The  liver  is  greatly  increased  in  size,  it  is  smooth  of  surface 
and  firm  of  consistency  and  its  cut  section  has  an  anaemic  waxy  appearance. 
Treated  with  iodine  tincture  it  turns  a  mahogany  brown  color.  The  degen- 
erative process  may  be  localized  in  one  part  of  the  organ  and  it  may  be  asso- 
ciated with  fatty  infiltration.  In  instances  due  to  syphilis  the  surface  may  be 
studded  with  nodules  (gummata).  The  amyloid  change  involves  the  walls 
of  the  small  blood-vessels,  but  not  the  liver  cells.  The  first  vessels  to  be  attacked 
are  those  of  the  median  portion  of  the  lobule,  later  the  capillaries  between 
the  lobules  and  their  supporting  connective  tissue  are  affected. 


452         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Symptoms.  These  are  not  definite  and  consist  chiefly  of  the  manifestations 
of  the  primary  disease.  There  is  no  jaundice  but  the  faeces  may  be  of  lighter 
color  than  normal;  the  secretion  of  bile  is  not  stopped.  Ascites  is  absent  but 
the  spleen  may  be  enlarged;  this  organ,  with  the  kidneys,  is  usually  the  seat 
of  associated  amyloid  degeneration.     Albuminuria  may  be  present. 

Physical  examination  reveals  a  much  enlarged  liver  of  increased  hardness 
and  smooth  surface,  except  in  syphiUs,  when  nodules  may  be  present.  The 
edge  of  the  organ  is  often  sharp  and  firm.    There  is  no  tenderness. 

The  diagnosis.  An  enlarged,  smooth  liver  in  a  tuberculous,  syphilitic 
or  otherwise  cachectic  patient  is  almost  invariably  the  seat  of  waxy  degenera- 
tion. For  further  points  in  differentiation  the  reader  is  referred  to  the  para- 
graph upon  the  diagnosis  of  cancer  of  the  liver  (p.  458). 

The  prognosis  is  that  of  the  primary  condition. 

Treatment  consists  in  removal  of  any  responsible  focus  of  suppuration  by 
surgical  means;  the  appropriate  treatment  of  pulmonary  tuberculosis  by 
means  of  diet,  tonics  and  change  of  climate,  and  of  syphilis  by  potassium  iodide 
is  necessary  should  either  of  these  diseases  be  the  causative  factor.  The 
mode  of  life  should  be  regulated  in  accordance  with  hygienic  principles; 
plenty  of  fresh  air,  moderate  exercise,  if  the  patient's  physical  condition  is 
fit,  and  simple  nourishing  food  in  proper  quantity  should  be  prescribed. 

Iron,  arsenic  and  the  bitter  tonics  may  be  administered  and  any  digestive 
disorders  should  be  corrected  by  the  usual  means. 

SYPHILIS  OF  THE  LIVER. 

Syphilis  of  the  liver  may  be  hereditary  or  acquired. 

1.  Hereditary  syphilis  of  the  liver  occurs  in  an  early  or  congenital  type 
and  as  delayed  heretary  syphilis  {syphilis  hereditaria  tarda).  The  congenital 
form  is  characterized  by  a  diffuse  or  localized  cellular  infiltration.  The 
former  results  in  slight  if  any  change  in  the  gross  appearance  of  the  organ 
other  than  moderate  enlargement  and  an  increase  in  density;  later  the  size 
of  the  organ  may  be  diminished  and  its  shape  distorted  due  to  the  connective 
tissue  prohferation  and  its  subsequent  contraction. 

The  circumscribed  infiltration  is  rare  and  produces  the  gumma,  a  manifes- 
tation seldom  observed  in  hereditary  syphilis. 

In  tardy  congenital  S}''philis  the  liver  is  also  enlarged  and  may  be  the  seat 
of  gummy  nodules.  Its  subjects  are  poorly  developed  and  there  may  be 
clubbing  of  the  fingers. 

2.  In  acquired  syphilis  of  the  liver  the  organ  may  be  involved  during  the 
secondary  stage  but  tertiary  lesions  are  much  more  common.  With  the  erup- 
tion there  may  be  jaundice  and  slight  enlargement  of  the  organ,  acute  yellow 


SYPHILIS    OF    THE    LIVER.  453 

atrophy  may  ensue  but  this  is  extremely  infrequent,  secondary  syphilis  of 
the  liver  being  usually  a  mild  affection. 

Tertiary  hepatic  syphilis  is  not  very  uncommon.  It  may  occur  as  a  diffuse 
increase  in  the  connective  tissue  of  the  organ  analogous  to  that  of  ordinary 
cirrhosis.  The  new  connective  tissue  is  often  unevenly  distributed;  most 
commonly,  however,  tertiary  syphilitic  disease  of  the  liver  is  characterized  by 
the  incidence  of  gummy  tumors.  These  are  nodular  growths  of  size  varying 
from  that  of  a  small  pea  to  that  of  a  base  ball;  they  are  situated  in  various 
parts  of  the  organ,  favorite  sites  being  the  upper  surface  near  the  suspensory 
ligament  and  upon  the  inferior  surface  in  the  connective  tissues  at  the  hilum; 
gummata  also  are  found  in  the  parenchyma  of  the  liver.  The  larger  tumors 
tend  to  undergo  cheesy  degeneration  and  sometimes  subsequent  calcification. 
Following  the  degeneration  the  nodules  contract  and  tend  to  distort  the  shape 
and  reduce  the  size  of  the  organ.  On  section  of  the  liver,  bands  of  connective 
tissue  and  the  cicatrices  which  have  resulted  from  the  contraction  of  the 
shrunken  gummata  may  be  observed. 

Symptoms.  These  may  not  suggest  the  nature  of  disease  in  any  manner 
whatever  unless  there  are  manifestations  of  syphilitic  disease  elsewhere  in 
the  body.  Usually  the  first  symptoms  are  those  of  obstruction  to  the  portal 
circulation;  ascites  may  be  present  and  there  may  be  slight  jaundice.  The 
patient  is  often  anaemic  and  his  appearance  and  symptoms  suggest  malignant 
disease. 

Physical  examination  may  reveal  the  presence  of  a  much  enlarged  liver 
with  bulging  of  the  lower  ribs  on  the  right  side  and  prominence  of  the  epigas- 
trium. The  organ  is  hard  and  firm;  nodules  may  be  palpable  upon  its 
surface.     The  spleen  may  be  increased  in  size. 

The  diagnosis  in  the  presence  of  a  specific  history  and  associated  lesions  is 
simple.     The  test  of  treatment  will  often  render  the  diagnosis  clear. 

The  prognosis  in  congenital  syphilis  is  fairly  good  under  proper  treatment 
although  in  many  instances  the  child  dies  within  a  few  days  of  birth.  In 
tertiary  syphilis  of  adult  life  in  otherwise  healthy  patients  the  prognosis  under 
energetic  treatment  is  also  favorable  but  marked  hepatic  and  splenic  enlarge- 
ment and  jaundice  are  considered  symptoms  of  bad  omen. 

Treatment.  In  the  congenital  form  of  the  affection  the  usual  treatment 
of  hereditary  syphilis  in  infants  is  indicated.  Mercury  may  be  given  either 
by  inunction  or  by  the  mouth,  the  former  being  preferable,  each  inunction 
consisting  of  about  15  grains  (i.o)  of  the  official  ointment,  a  fresh  site  being 
chosen  for  the  successive  frictions  as  suggested  under  the  treatment  of  con- 
stitutional syphilis.  If  it  is  preferred  to  give  the  drug  by  mouth  hydrargyrum 
cum  creta  is  as  good  a  preparation  as  any,  the  dose  for  a  child  of  2  months 
or  less  being  ^  a  grain  (0.032)  twice  daily;  an  older  child  may  receive  i  grain 
(0.065).     The  treatment  by  means  of  mercury  should  be  continued  daily 


454        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

for  several  months,  when  intermissions  of  increasing  length  are  to  be  advised. 
During  the  second  year  potassium  iodide,  in  small  doses,  should  be  added  and 
during  the  third  year  should  be  increased  in  amount.  In  the  fourth  year  the 
mercury  may  be  stopped  but  it  is  advisable  to  continue  the  administration 
of  the  iodide. 

Tertiary  syphilis  of  the  liver  in  adults  should  be  treated  according  to  the 
usual  methods  employed  in  the  third  stage  of  the  disease  (see  section  upon 
the  treatment  of  syphilis). 

ACUTE  YELLOW  ATROPHY  OF  THE  LIVER. 

Synonyms.  Acute  Parenchymatous  Hepatitis;  Icterus  Gravis;  Malignant 
Jaundice. 

Definition.  An  acute  destructive  affection  of  the  liver  characterized  by 
necrosis  and  atrophy  of  the  organ  and  associated  with  marked  constitutional 
symptoms. 

.Etiology.  The  disease  is  more  common  in  women  probably  because  of  its 
frequent  association  with  pregnancy;  it  is  most  usually  seen  in  early  adult  life 
but  has  been  observed  in  young  children.  It  has  occvirred  during  the  course 
of  the  acute  infectious  diseases,  hepatic  cirrhosis  and  syphilis;  alcoholism  and 
mental  emotion  have  been  considered  as  factors  in  its  production.  Micro- 
organisms, more  especially  the  colon  bacillus,  have  been  found  in  the  liver 
post  mortem  but  are  believed  to  have  no  connection  with  the  causation  of 
the  disease. 

Pathology.  After  death  the  liver  is  found  to  be  much  smaller  than  normal, 
reduction  to  even  one-fourth  of  its  usual  weight  having  been  observed.  The 
capsule  is  loose  and  wrinkled,  the  organ  is  greenish-yellow  in  color,  is  flat- 
tened and  flabby  and  there  is  no  distinct  demarcation  between  the  lobes. 
The  condition  is  similar  to  that  which  occurs  in  phosphorus  poisoning  as  a 
result  of  a  toxasmic  catarrhal  process  in  the  smaller  bile  ducts.  The  cut  sec- 
tion of  the  organ  is  yellow  or  yellow  and  red,  the  former  color  evidencing  an 
earlier  state  of  the  affection.  Under  the  microscope  the  liver  cells  are  found 
to  be  in  various  stages  of  disintegration,  only  a  few  having  retained  their 
normal  condition.  Areas  of  complete  necrosis  are  seen  in  which  the  hepatic 
cells  have  been  replaced  by  degenerated  matter  consisting  of  fatty  granular 
debris,  bits  of  connective  tissue,  bile  pigment,  and  crystals  of  leucin  and  tyro- 
sin.  There  is  a  catarrhal  inflammation  of  the  finer  bile  passages  and  there 
may  be  haemorrhages  between  the  hepatic  cells.  The  gall-ducts  and  bladder 
are  empty.  In  certain  instances  in  which  the  course  of  the  disease  is  not 
acute,  attempts  at  repair  may  take  place  either  by  hyperplasia  of  the  remain- 
ing normal  liver  cells  or  reproduction  of  cells  resembling  those  of  the  liver 
from  those  of  the  bile  passages  between  the  lobules. 


ACUTE    YELLOW    ATROPHY    OF    THE    LIVER.  455 

The  skin  and  the  organs  are  usually  bile-stained,  there  is  splenic  enlarge- 
ment with  granular  degeneration  of  the  renal  epithelium  and  fatty  infiltration 
of  the  cardiac  muscle.  There  are  haemorrhages  into  the  various  tissues  and 
the  fluid  in  the  serous  sacs  may  be  increased. 

Symptoms.  The  first  of  these  are  those  of  a  gastro-duodenitis  with  in- 
creasing jaundice.  These  persist  from  a  few  days  to  several  weeks;  there 
are  headache,  anorexia,  nausea,  vomiting  and  epigastric  distress;  these  are  fol- 
lowed, sometimes  suddenly,  by  constant  vomiting  and  at  times  by  hsemateme- 
sis,  delirium,  tremors,  convulsions  and  perhaps  coma.  The  jaundice  increases, 
there  are  haemorrhages  into  the  skin  and  mucous  membranes  and  in  women 
abortion  may  take  place.  Fever  is  not  characteristic  and  may  be  absent;  a 
moderate  ante  mortem  temperature  seldom  rising  above  ioi°  F.  (38.2°  C.) 
is  not  uncommon.  The  pulse  becomes  gradually  weak  and  rapid  and  the 
so-called  typhoid  state  becomes  evident. 

The  diminution  in  the  size  of  the  liver  is  rapid  and  the  shrunken  organ  may 
be  impossible  of  demonstration  by  percussion  owing  to  the  tympanitic  note 
over  the  hepatic  region  resulting  from  the  intervention  between  the  liver  and 
the  abdominal  parietes  of  distended  intestine.     The  spleen  is  enlarged. 

The  urine  is  of  high  specific  gravity,  colored  with  bile  pigment  and  may 
contain  casts  as  a  result  of  the  concomitant  degeneration  of  the  kidneys. 
The  urea  is  markedly  diminished,  even  absent  at  times,  but  the  ammonia  is 
increased.  Leucin  and  tyrosin  crystals  are  usually  present  and  may  be 
demonstrated  by  allowing  a  few  drops  of  urine  to  evaporate  upon  a  slide 
and  examining  the  result  with  the  microscope. 

The  faeces  are  usually  light  colored. 

The  diagnosis.  In  the  early  stages  it  is  impossible  to  separate  acute  yellow 
atrophy  from  acute  catarrhal  jaundice  and  it  must  be  remembered  that  cere- 
bral symptoms  may  occur  in  this  latter  affection;  usually  the  concurrence  of 
icterus  with  decrease  in  the  size  of  the  liver,  the  presence  of  leucin  and  tyrosin 
in  the  urine  and  the  symptoms  of  a  severe  intoxication  render  the  diagnosis 
in  the  later  stages  simple.  The  small  liver  will  differentiate  the  condition 
from  hypertrophic  cirrhosis,  and  acute  phosphorus  poisoning,  which  closely 
resembles  acute  yellow  atrophy  in  many  respects,  may  be  separated  by  the 
absence  of  leucin,  less  amount  of  tyrosin,  the  less  rapid  shrinkage  of  the  liver, 
the  more  severe  gastric  disturbance,  the  history  and  the  milder  cerebral 
symptoms. 

The  prognosis  is  extremely  unfavorable  but  a  few  instances  of  recovery 
have  been  observed.     The  usual  duration  of  the  disease  is  several  weeks. 

Treatment.  The  patient  should  be  kept  at  rest  in  bed,  the  diet  should 
consist  wholly  of  milk  and  other  easily  digestible  fluids  and  measures  should 
be  taken  to  disinfect  the  intestinal  tract  and  favor  the  elimination  of  toxic 
products  from  the  blood.     The  former  consideration  may  be  carried  out 


456        DISEASES   OF   THE   DIGESTIVE    SYSTEM    AND    PERITONiEUM. 

most  effectually  by  the  administration  of  bismuth  naphtholate  or  bismuth 
tetraiodophenolphthaleinate  (eudoxin)  either  alone  or  combined  with  phenyl 
salicylate  in  proportions  of  5  grains  (0.33)  of  one  of  the  bismuth  salts  to  3 
to  5  grains  (0.2  to  0.33)  of  the  latter  substance.  A  dose  should  be  given 
3  or  4  times  a  day.  The  bowels  should  be  kept  freely  open  by  means 
of  purges,  especially  calomel,  which  is  best  given  in  fractional  doses.  Elimi- 
nation through  the  kidneys  should  be  promoted  by  diuretic  drugs  such  as 
caffeine,  by  frequent  draughts  of  water  and  by  large  high  enemata  of  hot 
normal  saline  solution;  the  latter  is  a  most  effective  means  of  promoting  diur- 
esis and  may  be  employed  as  often  as  2  or  3  times  daily,  8  quarts  (litres)  or 
more  of  the  solution  being  given  at  each  occasion.  The  hot  saline  is  also 
taken  up  by  the  blood  and  serves  to  dilute  the  toxins  circulating  in  this 
fluid;  this  latter  consideration  may  also  be  favored  by  hypodermatoclysis  or 
intravenous  infusion  of  normal  saline  solution. 

The  vomiting  may  be  controlled  by  rest,  judicious  feeding  (diluted  or  pep- 
tonized milk),  pellets  of  ice,  small  doses  of  dilute  hydrocyanic  acid  or  of 
cocaine  hydrochloride,  menthol  -3V  of  a  grain  (0.002)  or  a  teaspoonful  (4.0) 
of  hot  water  frequently  repeated. 

For  the  nervous  symptoms  the  bromides  and  warm  baths  are  often  effective; 
hydrated  chloral  and  morphine  should  be  employed  only  when  absolutely 
necessary.  In  the  incidence  of  heart  weakness  or  collapse  free  stimulation 
is  indicated. 

NEOPLASMS  OF  THE  LIVER. 
Cancer  of  the  Liver. 

Of  the  malignant  tumors  of  the  liver  carcinoma  is  by  far  the  more  common 
type,  and  carcinoma  of  the  liver  of  internal  carcinoma  is  only  less  frequent 
than  that  of  the  uterus  and  stomach.  The  affection  is  rarely  primary,  being 
in  most  instances  secondary  to  similar  disease  of  other  structures.  Most 
often  it  is  secondary  to  carcinoma  elsewhere  in  the  portal  area,  particularly 
of  the  stomach.  It  is  most  common  in  men  in  advanced  adult  life  but  it 
has  been  observed  in  children.  A  hereditary  predisposition  is  considered 
to  be  of  some  influence  in  its  incidence. 

Pathology.     Primary  hepatic  carcinoma  occurs  in  three  types: 

1.  Massive  carcinoma  which  is  characterized  by  marked  increase  in 
the  size  of  the  organ  and  in  which  the  new  grovrth  is  distributed  uniformly 
through  a  considerable  portion  of  the  liver.  On  cut  section  the  growth  is 
firm  and  of  grayish-white  color  and  the  line  of  demarcation  between  it  and 
the  adjacent  hepatic  tissue  is  sharp. 

2.  Nodular  carcinoma.     In  this  type  of  the  disease  nodular  growths  of 


NEOPLASMS   OF   THE    LIVER.  457 

varying  size  are  distributed  through  the  organ.  One  of  the  nodules  is  often 
firmer  and  larger  than  the  others  and  is  the  primary  growth  from  which  the 
others  have  sprung. 

3.  Adeno-carcinoma  with  interstitial  hepatitis.  This  is  a  very  rare  form 
of  carcinoma  of  the  liver  in  which  the  organ  is  usually  small,  its  surface  is 
greenish  and  mottled  and  studded  with  nodules.  Cut  section  reveals  firm 
growths  in  great  numbers  between  which  are  bands  of  connective  tissue. 
The  liver  parenchyma  may  be  the  seat  of  h^-pertrophy. 

Secondary  carcinoma  of  the  liver  is  characterized  by  extreme  enlargement, 
its  surface  is  studded  with  nodules  which  are  also  distributed  evenly  through 
the  substance  of  the  organ;  rarely  one  lobe  only  may  be  affected.  The  nodules 
vary  in  size  and  consistence,  are  whitish  or  yellowish  in  color  and  those  just 
beneath  the  capsule  may  be  felt  through  the  abdominal  parietes  and  are  at 
times  umbilicated  (Farre's  tubercles).  Vascular  rupture  with  haemorrhage 
beneath  the  capsule  into  the  gall-bladder  or  peritonaeal  cavity  may  take  place. 

Histologically  hepatic  carcinomata  are  epitheliomata  of  the  alveolar  or 
trabecular  type.  The  cells  are  of  different  types,  polyhedral,  giant  or  more 
rarely  cylindrical;  at  times  different  varieties  of  cells  are  seen  in  the  same 
growth.  Degeneration  may  take  place  in  both  the  primary  and  secondary 
tumors  but  the  latter  are  more  particularly  susceptible.  The  changes  which 
may  take  place  are  of  different  varieties,  fatty  and  hyaline  degeneration, 
sclerosis  and  haemorrhage,  at  times  succeeded  by  suppiiration,  having  been 
described. 

Sarcoma  of  the  liver  is  very  rarely  primary;  secondary  hepatic  sarcoma  is 
not  especially  uncommon.  Melano-sarcoma  is  the  most  frequent  type  although 
instances  of  lympho-sarcoma,  myxo-sarcoma  and  glio-sarcoma  have  been 
observed.  Melano-sarcoma  is  usually  secondary  to  similar  growths  in  the 
orbit  or  it  may  occur  in  association  with  generalized  melano-sarcoma.  The 
occurrence  of  melanotic  tumors  in  the  skin  may  suggest  the  possibility  of 
similar  growth  in  the  liver. 

Symptoms.  These  consist  of  progressive  emaciation,  weakness  and  pros- 
tration, with  hepatic  enlargement.  Digestive  disorders  are  common,  such  as 
anorexia,  nausea,  vomiting  and  pain  or  a  feeling  of  weight  in  the  epigastrium 
or  in  the  region  of  the  liver.  The  pain  varies;  it  may  be  wholly  wanting  or 
it  may  be  of  severe  character  and  is  sometimes  referred  to  the  right  shoulder. 
Jaundice  of  moderate  degree  may  be  present;  it  is  said  to  exist  in  about  50  per- 
cent, of  patients.  The  urine  is  colored  with  bile  pigments  if  there  is  jaundice 
but  the  stools  are  seldom  clay-colored.  Ascites  occurs  both  in  the  rare 
forms  of  cancer  with  cirrhosis  and  as  a  result  of  pressure  upon  the  portal 
vein  or  of  peritonaeal  metastases.  If  tapping  reveals  the  presence  of  blood- 
tinged  fluid  in  association  with  a  grovi1;h  of  the  liver  the  probability  of 
malignant  tumor  is  great. 


458         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

The  blood  is  that  of  a  secondary  anaemia  and  consequent  oedema  is  fre- 
quent. A  febrile  movement  is  not  uncommon  especially  in  the  late  stages; 
it  is  often  continuous — 100°  to  102°  F.  (37.8°  to  38.9°  C.) — but  may  be  inter- 
mittent.    Chills  may  be  noted. 

Physical  Examination.  Upon  inspection  the  patient  is  seen  to  be  emaciated 
and  cachectic  in  appearance.  Tlie  skin  may  be  of  icteric  color  and  there  is 
usually  a  prominence  of  the  upper  abdomen  with  a  dilatation  of  the  superfi- 
cial veins.  Palpation  reveals  the  edge  of  the  liver  from  an  inch  or  two  below 
the  margin  of  the  ribs  to  the  level  of  the  umbilicus  or  even  lower.  The  surface 
of  the  organ  may  be  smooth  but  in  nodular  cancer  the  prominences  and  some- 
times the  depressions  in  their  centers  may  be  felt.  Tenderness  may  be 
present.  The  increase  in  size  is  also  evident  upon  percussion  and  it  usually 
involves  the  whole  organ  but  may  affect  one  lobe  more  than  the  other.  Splenic 
enlargement  is  not  characteristic  nor  frequent. 

Primary  neoplasms  may  be  difficult  of  differentiation  from  those  of  secondary 
type  unless  there  is  a  demonstrable  primary  growth  elsewhere  in  the  body. 

The  diagnosis  may  be  difficult  in  the  absence  of  primary  carcinoma  of 
other  structures.  The  presence  of  firm  nodules  on  the  svirface  of  the  organ 
simplifies  the  diagnosis  but  the  smooth  cancerous  liver  is  a  more  complicated 
problem.  It  may  be  differentiated  from  the  fatty  liver  by  its  hardness,  the 
absence  of  cachexia  and  jaundice.  These  two  latter  are  also  absent  in  the 
amyloid  liver  and  here  the  spleen  is  usually  enlarged.  In  abscess  we  have 
the  history  of  colitis  or  the  presence  of  a  septic  temperature  to  aid  us,  the 
organ  is  usually  soft  and  fluctuation  may  be  elicited.  The  nodules  which 
occur  in  hydatid  disease  with  an  enlarged  liver  are  soft,  the  cachexia  is  not 
present  and  the  course  of  the  disease  is  more  protracted  than  that  of  cancer. 
Aspiration  of  one  of  the  cysts  may  show  the  presence  of  booklets. 

Another  difficult  problem  is  the  separation  of  the  amyloid  liver  with  a  surface 
studded  with  gummata.  Here  the  presence  of  a  history  of  syphilis  and  the 
benign  course  of  the  affection  are  diagnostic  points.  In  hypertrophic  cirrhosis 
we  have  an  enlarged  liver  with  jaundice  but  the  onset  of  cachexia  is  deferred, 
wasting  is  not  extreme,  pain  is  absent,  the  liver  is  smooth  and  the  ascitic  fluid 
does  not  contain  blood  nor  cancer  cells;  the  spleen  is  usually  enlarged.  That 
form  of  carcinoma  which  is  associated  with  cirrhosis  is  extremely  difficult  of 
differentiation  from  atrophic  cirrhosis;  the  emaciation  is,  however,  more 
rapid  in  the  former  affection. 

Melano-sarcoma  usually  follows  pigmented  growths  in  other  parts,  partic- 
ularly the  choroid  of  the  eye  and  the  skin;  there  is  great  enlargement  in  the 
liver  and  often  metastatic  growths  in  the  kidneys,  lungs  and  other  organs  are 
present. 

The  importance,  in  instances  of  hepatic  affection  in  which  a  malignant 
nature  is  suspected,  of  thoroughly  searching  for  the  presence  of  primary  cancer 


CANCER    OF    THE    LIVER.  459 

elsewhere,  cannot  be  over-rated.  The  stomach,  uterus  and  rectum,  in  partic- 
ular, should  be  investigated  by  all  the  means  at  our  command. 

The  prognosis  of  hepatic  cancer  is,  of  course,  distinctly  unfavorable,  the 
condition  usually  resulting  in  death  in  a  few  months;  exceptionally  life  may  be 
prolonged  for  a  year  or  slightly  longer. 

Treatment.  Medical  treatment  can  be  but  palliative.  For  the  pain  the 
hypodermatic  administration  of  morphine  may  be  prescribed  without  com- 
punction for  the  character  of  the  disease  is  such  as  to  render  the  induction  of 
the  habit  harmless.  The  addition  of  small  quantities  of  atropine  to  the  former 
drug  will  lessen  the  tendency  to  constipation.  This  symptom,  when  present, 
is  preferably  treated  by  means  of  the  vegetable  purges  such  as  cascara,  senna, 
aloes,  etc.;  the  saline  waters,  according  to  German  observers,  should  not  be 
employed. 

Hepatic  pain  may  be  relieved  by  the  application  of  hot  or  cold  compresses, 
poultices,  anodyne  plasters  or  counterirritants  such  as  tincture  of  iodine,  or 
liniments. 

The  appetite  may  be  improved  by  the  vegetable  bitters  and  dilute  hydro- 
chloric acid — lo  drops  (0.66)  in  a  glass  of  water  with  each  meal. 

Vomiting  may  be  controlled  by  the  administration  of  bits  of  cracked  ice, 
sodium  bicarbonate  and  cerium  oxalate  in  milk,  small  doses  of  dilute  hydro- 
cyanic acid  or  of  creosote.  Gastric  lavage  is  often  effective.  Intestinal 
fermentation  is  benefited  by  the  bismuth  salts  especially  the  naphtholate  or 
iodophenolphthaleinate  in  doses  of  5  grains  (0.33)  3  times  daily. 

The  pruritus  which  sometimes  accompanies  the  jaundice  may  be  relieved 
by  warm  baths  containing  sodium  carbonate,  lotions  of  i  to  50  phenol 
and  the  other  means  suggested  under  the  treatment  of  catarrhal  jaundice. 
Calcium  chloride,  15  grains  (i.o)  3  times  daily  and  hypodermatic  injections 
of  pilocarpine,  |  of  a  grain  (o.oii),  are  said  to  be  effective. 

The  diet  should  be  nourishing  and  easily  digestible.  Frequent  small  meals 
are  preferable  to  larger  ones  at  longer  intervals.  Milk  when  well  borne  is 
very  valuable  but  if  large  amounts  are  taken  at  once  heavy  curds  may  form  in 
the  stomach.  To  obviate  this  Vichy  or  lime  water  may  be  added.  Kumyss 
and  matzoon  are  excellent  substitutes  when  the  patient  cannot  take  milk 
or  is  tired  of  it.  Meat  and  fats  are  often  not  well  tolerated  but  the  various 
meat  extracts  may  be  employed  if  desired.  Cereals  and  gruels  are  excellent. 
Usually  the  patient  may  be  allowed  to  select  the  foods  which  he  likes  if  they 
are  not  disturbing  to  the  digestion. 

Surgical  treatment  may  be  effective  when  the  growth  is  single,  primary  and 
in  a  favorable  situation.  Recovery  has  followed  in  at  least  one  instance  of 
secondary  tumor,  the  primary  growth  in  the  stomach  having  been  excised  and 
at  the  same  time  a  secondary  nodule  in  the  liver  was  extirpated.  The  advances 
which  are  daily  being  made  in  surgical  technique  lead  us  to  hope  that  it  may 


460        DISEASES   OF   THE   DIGESTIVE    SYSTEM   AND    PERITONEUM. 

soon  be  possible  to  undertake  operations  upon  the  liver  which  were  previously 
considered  impracticable. 
If  marked  ascites  is  present  repeated  tapping  may  be  necessary. 

PARASITES  OF  THE  LIVER. 
Echinococcus  Disease  of  the  Liver. 

Synonym.     Hydatid  Disease  of  the  Liver. 

Definition.  A  disease  of  the  hver  due  to  invasion  of  the  embryo  or  larva 
of  the  tcBnia  echinococcus  and  characterized  by  the  formation  of  cysts  within 
the  substance  of  the  organ. 

.etiology  and  Pathogenesis.  The  tc^nia  echinococcus  is  a  minute  cestode  of 
three  or  four  segments  and  about  -i  of  an  inch  (4  to  5  mm.)  in  length;  the  head 
is  small  and  possesses  four  sucking  disks  and  a  rostellum  with  two  rows  of  hook- 
lets.  The  natural  habitat  of  this  parasite  is  the  upper  intestine  of  the  dog.  The 
worm  is  rarely  met  in  the  United  States  possibly  because  it  is  so  small  as  to 
be  easily  overlooked.  Echinococcus  disease  is  most  common  in  those  countries 
where  the  relation  between  dogs  and  men  is  intimate,  as  in  Iceland  and  Aus- 
tralia. 

The  terminal  segment  of  the  parasite,  containing  several  thousand  eggs,  is 
cast  off  by  the  dog  in  the  intestinal  evacuations  of  this  animal  and  entering 
the  human  alimentary  tract  with  food  or  drink,  the  egg  shell  is  dissolved  and 
the  larva  is  liberated.  It  bores  its  way  into  some  branch  of  the  portal 
circulation  and  is  carried  by  the  blood  stream  to  the  liver.  Here  it  lodges 
and  the  booklets,  by  means  of  which  it  entered  the  blood-vessel,  disappear. 
The  embryo  now  becomes  a  small  cyst  consisting  of  two  layers,  the  external 
or  ectocyst  which  is  laminated  and  cuticular  in  structure  and  the  internal 
or  endocyst,  a  parenchymatous  or  germinal  layer.  The  fluid  of  the  cyst  is 
clear  and  the  whole  vesicle  is  enclosed  by  a  capsule  of  connective  tissue  which 
develops  as  a  result  of  inflammatory  reaction.  When  the  primary  cyst  has 
increased  to  a  diameter  of  |-  to  f  of  an  inch  (15  to  20  mm.)  buds  develop 
from  the  germinal  layer  which  gradually  become  cysts  themselves  with  a 
structure  identical  with  that  of  the  primary  vesicle.  These  daughter  cysts 
are  at  first  attached  to  the  lining  of  the  mother  cyst  but  later  free  themselves 
and  become  in  turn  the  parents  of  a  third  generation  of  vesicles. 

From  the  granular  inner  layer  of  parent  and  daughter  cysts  brood  capsules 
develop  by  a  budding  process,  and  from  their  lining  membrane  projections 
are  formed  which  ultimately  become  scolices  which  really  are  the  heads  of 
tcenia.  echinococci  with  their  suckers  and  booklets.  These  when  freed  and 
ingested  by  the  dog  may  develop  into  the  adult  parasite. 

The  preceding  is  the  usual  form  of  the  development  of  the  echinococcus  in 


PARASITES    OF    THE    LIVEK.  46 1 

man;  at  other  times  the  daughter  and  granddaughter  cysts  remain  within  the 
parent  and  in  animals  the  buds  may  force  their  way  between  the  two  layers 
of  the  cyst  wall  and  grow  outward — the  exogenous  type.  In  still  another 
type — the  multilocular — the  buds  which  are  formed  from  the  parent  cyst 
become  completely  cut  off  and  are  enclosed  by  a  firm  connective  tissue  capsule; 
a  number  of  these  may  unite  and  form  a  dense  mass  of  fibrous  tissue  in  the 
meshes  of  which  are  spaces  of  about  the  size  of  a  large  pea  in  which  at  times 
booklets  and  scolices  may  be  found. 

The  fluid  contained  in  the  young  cysts  is  clear,  of  a  specific  gravity  of  1,005 
to  1,009  or  slightly  higher  and  contains  no  albumin  except  after  a  number  of 
tappings;  at  times  traces  of  sugar,  succinic  acid  and  haematoidin  are  present. 
Scolices  and  booklets  are  usually  found  and  are  characteristic  of  hydatid 
disease. 

The  cysts  vary  in  size  from  that  of  a  pin  head  to  5  inches  (12  cm.)  or  more 
in  diameter  and  are  of  slow  growth;  the  parasite  may  remain  alive  perhaps  as 
long  as  20  years.  When  death  finally  takes  place  the  cyst  walls  contract  and 
the  contents  becomes  inspissated;  partial  calcification  may  occur.  Rupture 
into  the  bile  ducts,  the  vena  cava,  the  intestine  and  elsewhere  may  take  place 
and  is  a  serious  complication;  the  same  is  true  of  suppuration. 

Symptoms.  Small  cysts  are  often  unsuspected  until  revealed  at  autopsy. 
The  larger  ones  give  rise  to  the  symptoms  of  hepatic  tumor  associated  with  a 
very  slow  and  gradual  decline  in  health.  The  large  cysts  cause  a  dragging 
sensation  referred  to  the  region  of  the  liver,  jaundice,  if  there  is  obstruction 
to  the  flow  of  bile,  and  when  there  is  interference  with  the  action  of  the  heart 
or  lungs,  dyspnoea  and  irregular  cardiac  action. 

Suppuration  gives  rise  to  a  septic  temperature  with  rigors  and  sweats  and, 
if  rupture  takes  place,  various  symptoms  result  depending  upon  the  site  of  the 
rupture.  Invasion  of  the  lungs  may  be  accompanied  by  the  expectoration  of 
sputum  containing  booklets;  rupture  into  the  bile  passages  is  succeeded  by 
jaundice  and  by  the  evacuation  of  faeces  in  which  booklets  may  be  found; 
rupture  into  the  stomach  may  be  followed  by  vomiting  of  booklets  and  cysts; 
the  bursting  of  a  cyst  into  the  vena  cava  causes  interference  with  the  right 
heart  action  and  thrombosis  of  the  lungs  due  to  the  lodgment  of  cysts.  The 
cysts  may  also  rupture  into  the  pericardium  in  which  case  pericarditis  ensues; 
into  the  peritonaeal  cavity  with  resulting  peritonitis;  or  externally  through  the 
abdominal  wall.  Urticaria  may  appear  coincident  with  rupture  or  even 
with  aspiration,  due  perhaps  to  the  absorption  of  a  toxic  material  contained 
in  the  fluid. 

The  physical  signs  depend  upon  the  situation  of  the  tumor.  Cysts  near  the 
upper  surface  of  the  liver  may  manifest  themselves  by  demonstrable  elastic 
or  fluctuating  swellings  and  may  give  the  so-called  hydatid  fremitus  which  is 
elicited  by  applying  one  hand  to  the  tumor  and  at  the  same  time  percussing 


462         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

lightly  with  the  other.  The  fremitus  is  evidenced  by  a  vibrating  or  trembling 
movement  thought  to  be  produced  by  the  impact  of  the  daughter  cysts  against 
one  another.  A  furrow  may  appear  on  deep  inspiration  below  the  costal 
margin  and  over  the  cyst  (Lennhoff 's  sign). 

The  diagnosis  often  requires  puncture  and  aspiration  of  the  cyst  contents 
for  its  confirmation;  the  characteristics  of  the  fluid  withdrawn  are  as  described 
above.  The  presence  of  hooklets  is  pathognomonic,  and  that  of  glucose, 
probable,  evidence  of  hydatid  disease.  Hepatic  syphilis  may  be  differentiated 
by  its  history,  and  cancer  of  the  liver  by  its  more  rapid  cachexia. 

The  prognosis  in  instances  of  the  affection  which  are  characterized  by 
evident  symptoms  is  unfavorable,  unless  operative  interference  is  undertaken, 
except  in  the  instance  of  spontaneous  external  rupture. 

Treatment.  Prophylaxis  consists  in  impounding  and  destroying  stray 
dogs  and  also  in  decreasing  the  number  of  these  animals  by  means  of  an  in- 
creased license  fee.  Strict  cleanliness  should  be  observed  by  those  who  keep 
dogs  in  the  house  as  the  ova  are  to  a  very  great  extent  conveyed  by  the  faeces 
of  these  animals.  Where  the  disease  is  prevalent  all  drinking  water  should 
be  filtered  and  boiled  and  all  fruit  and  vegetables  which  are  eaten  uncooked 
must  be  thoroughly  washed  with  filtered  and  boiled  water.  Meat  should  be 
inspected  for  the  echinococcus  and  all  the  offal  of  infected  sheep  and  oxen 
should  be  burned  lest  it  be  eaten  by  dogs.  Pet  dogs  should  receive  an 
anthelmintic  about  once  a  year. 

Numerous  drugs  have  been  employed  in  the  treatment  of  echinococcus 
disease  but  none  of  them  has  proved  of  any  benefit,  the  only  efficient  curative 
means  which  we  possess  being  surgical. 

Simple  aspiration  of  the  cyst  contents,  a  canula  of  moderate  size  being 
employed,  may  result  in  cure  but  is  not  to  be  undertaken  without  due  con- 
sideration, for  death  has  been  known  to  follow  the  operation.  Aspiration  is 
contra-indicated  if  suppuration  is  present.  Aspiration  with  injection  of  anti- 
septic solutions  such  as  i  to  1,000  mercury  bichloride,  5  percent,  copper  sul- 
phate and  0.5  percent,  beta-naphthol  has  been  recommended  but  is  not  with- 
out danger  and  is  to  be  avoided. 

The  treatment  by  means  of  electrolysis  is  carried  out  by  passing  two  needles, 
each  connected  to  the  negative  pole  of  a  galvanic  battery,  into  the  cyst,  while 
a  sponge  electrode  attached  to  the  positive  pole  is  applied  externally  to  the 
abdomen  or  over  the  cyst.  Success  has  followed  this  method  in  a  few  instances 
but  it  is  not  to  be  advised. 

Radical  surgical  treatment  should  always  be  employed  when  possible,  the 
object  being  to  remove  the  cyst  wall  and  its  contents  entire;  if  this  is  imprac- 
ticable simple  evacuation  of  the  fluid  may  result  in  cure.  When  suppuration 
has  taken  place  the  management  of  the  condition  is  identical  with  that  of 
abscess. 


DISEASES    OF    THE    HEPATIC    BLOOD-VESSELS.  463 

Other  Parasites  of  the  Liver. 

The  liver  is  subject  to  diseases  due  to  other  forms  of  parasites  but  these 
are  rare  and  of  interest  rather  to  the  pathologist  than  the  practitioner.  The 
peniastomum  denticulatum,  the  larva  of  the  pentastomiim  or  lingiialula  tcBnioides, 
may  be  found  in  the  organ.  This  is  a  lancet-shaped  worm,  the  male  being 
slightly  less  than  an  inch  (1.8  to  2.5  cm.)  long  while  the  length  of  the  female 
is  from  3  to  5  inches  (8  to  13  cm.). 

The  coccidiiim  ovi forme  is  common  in  the  liver  of  the  rabbit  and  maybe 
found  in  the  human  being  where  it  produces  whitish  nodules  varying  in  size 
from  that  of  a  pin  head  to  that  of  a  small  pea.  The  accompanying  symp- 
toms are  intermittent  fever,  nausea,  diarrhoea  and  enlargement  and  tenderness 
of  the  liver. 

The  cysticercus  celhdosce  is  rarely  observed  in  the  liver  of  man. 

DISEASES  OF  THE  HEPATIC  BLOOD-VESSELS. 

Anaemia  of  the  liver  is  productive  of  no  especial  symptoms.  The  anaemic 
condition  which  is  observed  after  death  in  the  liver  of  amyloid  or  fatty  degen- 
eration is  probably  not  an  index  of  the  state  of  the  organ  during  life. 

Hyperaemia  of  the  liver  occurs  in  two  varieties: 

I.  Active  Hypercemia  takes  place  after  eating  a  full  meal  and  is  especially 
marked  in  individuals  who  eat  and  drink  excessively;  in  these  subjects  the 
condition  may  even  be  continuous.  If  the  over-eating  and  drinking  is  persis- 
ted in,  functional  disturbances  and  even  organic  structural  change,  consisting 
in  an  over-production  of  connective  tissue,  may  result.  Active  hyperaemia 
also  occurs  in  diabetes  mellitus  and  in  the  acute  infectious  diseases  and 
as  a  result  of  suppressed  menstruation  and  after  the  suppression  of  a  haemor- 
rhoidal  flux. 

Symptoms.  These  are  not  marked  nor  important.  The  condition  may  be 
the  cause  of  the  distress  and  feeling  of  weight  of  which  persons  who  habitually 
eat  and  drink  too  much  complain  and  which  is  referred  to  the  region  of  the 
liver.     The  size  of  the  organ  is  probably  subject  to  daily  fluctuations. 

Treatment  consists  chiefly  in  dietetic  measures;  a  moderate  and  easily 
digestible  diet  comprised  of  milk,  thin  soups,  etc.,  should  be  substituted  for 
that  to  which  the  patient  has  been  accustomed.  Plenty  of  water  should  be 
taken  but  alcohol,  with  fats  and  sugar,  should  be  forbidden. 

The  pain  and  discomfort  over  the  liver,  if  severe,  may  be  relieved  by  the 
application  of  flaxseed  poultices,  cold  compresses  or  dry  cups.  Intestinal 
antiseptics  especially  bismuth  naphtholate  or  phenolphthaleinate  (eudoxin) 
in  doses  of  5  grains  (0.33)  3  times  a  day  should  be  given,  any  gastric  irritation 
should  receive  appropriate  treatment  and  the  bowels  should  be  kept  freely 


464        DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

open  by  means  of  fractional  doses  of  calomel  and  the  saline  laxative  waters. 
Ammonium  chloride  in  20  grain  (1.33)  doses  is  said  to  have  some  influence 
in  decreasing  the  congestion  of  the  affected  organ. 

In  many  instances  a  sojourn  at  one  of  the  spas  such  as  Saratoga,  where  the 
Hathorn  water  is  particularly  indicated,  is  advisable;  Vichy  upon  the  continent 
of  Europe  is  recommended  as  a  resort  for  these  patients. 

2.  Passive  Hypercemia  is  a  much  more  common  and  important  affection 
than  the  foregoing. 

.etiology.  The  condition  is  the  result  of  obstruction  to  the  flow  of  blood 
through  the  liver  to  the  heart.  The  chief  cause  is  valvular  endocarditis  but 
passive  congestion  of  the  liver  also  occurs  in  pulmonary  emphysema  and 
sclerosis,  thoracic  tumors,  pleuritic  diseases  and  any  condition  in  which 
pressure  is  exerted  upon  the  vena  cava. 

Pathology.  The  liver  is  increased  in  size,  firm  in  consistence  and  dark 
reddish  in  color.  Its  vessels  are  distended  with  blood,  the  intra-lobular  vein 
and  the  neighboring  capillaries  being  especially  affected  in  this  respect.  On 
section  the  "nutmeg"  appearance,  which  is  the  result  of  the  alternating  hyper- 
aemia  and  anaemia  of  the  hepatic  and  portal  districts,  is  apparent.  The  in- 
creasing distention  of  the  vessels  in  the  central  portions  of  the  lobules  finally 
results  in  an  atrophy  of  the  adjacent  liver  cells;  there  is  a  deposition  of  dark 
pigment,  the  blood-vessels  are  finally  occluded  and  there  is  an  increase  of  con- 
nective tissue.  In  the  final  stage  of  chronic  passive  congestion  the  organ  is 
decreased  in  size  but  its  surface  is  smooth  in  contra-distinction  to  the  condition 
obtaining  in  atrophic  cirrhosis  in  which  the  surface  of  the  liver  is  roughened. 

Sjrmptoms.  There  is  usually  gastric  irritation  with  vomiting,  sometimes 
of  blood;  ascites,  at  times  followed  by  general  oedema,  is  common  in  the  later 
stages.  There  may  be  slight  jaundice,  with  dark  urine  and  light  colored 
stools. 

The  physical  signs  consist  of  a  primary  enlargement  of  the  liver,  often 
with  tenderness,  followed  by  a  contraction  of  the  organ.  The  enlarged  liver 
may  pulsate  as  a  result  of  the  regurgitation  of  blood  from  the  right  side 
of  the  heart.  This  is  not  to  be  confounded  with  the  throbbing  which  may  be 
transmitted  from  the  over-acting  heart.  In  this  latter  condition  the  liver 
appears  to  move  downward  while  in  the  former  the  organ  appears  to  dilate 
uniformly.     The  spleen  is  often  increased  in  size. 

Treatment  consists  in  restoring  the  circulation  to  its  normal  state  which 
is  often  possible,  when  the  condition  is  the  result  of  valvular  heart  disease,  by 
the  administration  of  cardiac  tonics.  Co-existing  pulmonary  disease  should 
receive  appropriate  treatment  and  abdominal  paracentesis  may  be  necessary. 
Confinement  to  bed  is  usually  indicated. 

The  congestion  of  the  liver  may  be  further  relieved  by  saline  laxatives 
and  hydrogogue  cathartics  such  as  elaterium,  jalap,  etc.     Calomel  and  blue 


THROMBOSIS    AND    EMBOLISM    OF    THE    PORTAL    VEIN.  465 

mass  are  also  valuable.  The  method  of  depletion  advocated  by  Hay,  which 
consists  in  the  administration  before  retiring  of  2  ounces  (60.0)  of  magnesium 
sulphate  which  have  been  dissolved  in  boiling  water  and  then  allowed  to  cool, 
is  an  excellent  method  of  relieving  the  portal  congestion.  The  general  dropsy 
may  be  diminished  by  eliminating  the  chlorides  from  the  diet  (see  the  section 
on  the  treatment  of  the  oedema  of  chronic  nephritis).  The  withdrawal  of 
from  15  to  20  ounces  (450.0  to  600.0)  of  blood  directly  from  the  liver  may 
be  practised  but  is  not  without  danger. 

The  pain  over  the  liver  may  be  relieved  by  the  means  suggested  in  acute 
hepatic  congestion  (p.  463).  The  diet  should  be  nourishing  and  easily 
digestible  because  of  the  possibility  of  increasing  the  dropsy. 

During  convalescence  a  residence  at  one  of  the  water  cures  suggested  under 
the  treatment  of  active  hyperaemia  is  often  of  benefit  to  the  patient. 

Thrombosis  and  Embolism  of  the  Portal  Vein. 

Thrombosis  of  the  small  branches  of  the  portal  vein  occurs  as  a  result  of 
the  obliteration  which  takes  place  in  hepatic  cirrhosis;  obstruction  of  larger 
branches  may  follow  cancerous  invasion,  the  lodgment  of  a  parasite  or  of  a 
calculus  which  has  ulcerated  through  the  vessel  wall.  The  blood  may  coagu- 
late in  the  vein  in  cirrhosis  and  sj'philis  of  the  liver  or  the  vessel  may  become 
occluded  as  a  result  of  a  proliferative  inflammation  of  its  wall.  Collateral 
circulation  may  become  established  around  the  obstruction  and  the  affected 
vessel  may  degenerate  into  a  fibrous  cord. 

Symptoms.  Associated  with  those  of  cirrhosis  or  of  another  of  the  causa- 
tive conditions  the  sudden  occurrence  of  ascites,  extreme  distention  of  the 
branches  of  the  portal  circulation  with  splenic  enlargement,  hasmatemesis 
and  bloody  stools,  is  suggestive  of  portal  thrombosis.  The  diagnosis  is  a 
very  difficult  one. 

Hepatic  infarct  is  not  common  and  is  of  no  especial  clinical  importance 
except  when  the  embolus  is  septic. 

Pylephlebitis  is  probably  consequent  upon  portal  thrombosis  but  is  of  no 
particular  significance  unless  the  thrombus  is  infective.  Septic  pylephlebitis 
follows  the  lodgment  of  an  infective  embolus  from  some  part  of  the  territory 
of  the  portal  circulation.  It  may  occur  in  dysenteric  conditions  or  in  sepsis 
of  the  umbilical  vein  in  the  new-born;  its  chief  importance  is  its  relation  to 
hepatic  abscess. 

The  symptoms  are  the  usual  ones  of  pyaemic  infection,  irregular  tempera- 
ture with  rigors,  sweats  and  prostration.  There  is  usually  pain  over  the 
liver  and  jaundice  with  the  manifestations  of  portal  obstruction.  Co-existent 
purulent  peritonitis  has  been  observed. 

Changes  in  the  Hepatic  Artery  and  Vein  are  uncommon.  The  artery 
30 


466         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

may  be  the  seat  of  dilatation  in  cirrhosis  of  the  Hver.  Arteriosclerosis  and 
endarteritis  as  well  as  aneurysm  of  the  hepatic  artery  have  been  observed. 
The  last  of  these  is  evidenced  by  an  expansile  tumor  over  which  a  bruit  may 
be  audible.  Its  symptoms  are  pain  over  the  liver,  jaundice  from  obstruction 
of  the  biliary  ducts  due  to  pressure,  melaena,  and  the  vomiting  of  blood. 

The  hepatic  vein  may  be  dilated  in  conjunction  with  right  cardiac  enlarge- 
ment. Embolism  from  the  right  auricle  has  been  noted  and  a  stenosis  of  the 
openings  of  the  veins  has  been  described  as  occurring  in  connection  with 
a  fibrous  obliteration  of  the  inferior  vena  cava. 


DISEASES  OF  THE  BILIARY  TRACT. 
JAUNDICE. 

Synonym.    Icterus. 

Definition.  A  condition,  rather  sypmtom  than  disease,  characterized  by  a 
yellowish  discoloration  of  the  skin  and  other  tissues,  as  well  as  of  the  body 
secretions,  by  the  bile  pigments.  Jaundice  was  formerly  considered  as  occur- 
ring in  two  types,  hepatogenous,  or  obstructive,  and  hcematogenous.  At  present 
it  is  held  as  probable,  if  not  certain  that  there  is  no  haematogenous  jaundice 
but  that  obstruction  is  responsible  for  the  condition  in  all  instances. 

Obstruction  to  the  normal  flow  of  bile  and  consequent  jaundice  may  result 
from  various  causes  of  which  the  following  are  the  most  frequent:  i. 
Inflammation  with  accompanying  swelling  of  the  duodenal  mucous  membrane 
or  of  the  lining  of  the  bile  duct.  2.  Pressure  upon  the  bile  ducts  exerted 
from  without  such  as  may  occur  in  instances  of  tumors  of  the  gall-bladder, 
liver,  pancreas  or  stomach,  particularly  cancer  of  the  pylorus.  Omental 
tumors,  displaced  kidneys,  enlarged  glands  in  the  fissure  of  the  liver,  faecal 
masses,  the  pregnant  uterus  and  aneurysms  of  the  abdominal  vessels  are  less 
common  external  causes  of  obstruction.  3.  Obstruction  of  the  biliary 
passages  from  internal  causes  such  as  calculi,  parasites,  inflammatory  stric- 
tures or  tumors  of  the  duct  itself  or  of  the  duodenum  at  its  orifice.  4. 
Reduced  pressure  in  the  hepatic  blood-vessels,  while  a  higher  pressure  obtains 
in  the  bile  passages,  favors  the  resorption  of  bile  from  the  latter. 

Acute  Catarrhal  Jaundice. 

Synonyms.  Duodeno-cholangitis;  Icterus  Catarrhalis;  Inflammation  of  the 
Common  Bile  Duct. 

Definition.  An  affection  characterized  by  icterus  of  the  tissues  occurring 
as  a  result  of  an  obstruction  to  the  flow  of  bile  due  to  a  catarrhal  inflammation 
of  the  mucous  membrane  of  the  bile  ducts  and  of  the  duodenum. 

JEtiology.     Cholangitis  is  usually  a  sequence  of  the  extension  of  an  inflam- 


ACUTE  CATARRHAL  JAUNDICE.  467 

mation  of  the  gastric  and  duodenal  lining  into  the  common  bile  duct.  These 
latter  conditions  may  be  caused  by  exposure,  errors  in  diet,  over-indulgence 
in  alcohol,  tea  or  coffee,  over-work,  mental  emotion,  or  they  may  complicate 
the  acute  infectious  diseases  such  as  pneumonia  and  enteric  fever.  The 
passive  congestion  which  occurs  in  chronic  endocarditis  and  nephritis  may 
also  result  in  jaundice  of  this  type.  An  epidemic  catarrhal  jaundice  has  been 
described. 

Pathology.  The  distinctive  lesion  is  a  swelling  and  congestion  of  the  mucous 
lining  of  the  common  bile  duct;  the  process  may  extend  to  the  cystic  duct  or 
even  to  the  hepatic  duct  and  its  ramifications.  The  lumen  of  the  duct  is  usu- 
ally filled  with  mucus,  a  plug  of  which  often  occludes  its  orifice.  This  plug 
may  be  expelled  by  pressure,  following  which  free  passage  is  afforded  to  the 
bile.  The  liver  itself  may  be  slightly  swollen,  its  color  is  lighter  than  normal 
and  its  tinge  icteroid.  If  the  affection  is  protracted  the  retained  secretion 
may  cause  sufficient  irritation  to  bring  about  an  increase  of  the  connective 
stroma  of  the  organ  and  a  consequent  cirrhosis  with  atrophy  of  the  hepatic 
cells  may  result. 

Symptoms.  Usually  manifestations  pointing  to  gastric  disturbance,  such 
as  anorexia,  a  coated  tongue,  nausea,  vomiting  and  constipation,  are  first 
noticed.  Pain  is  not  common  but  there  may  be  slight  epigastric  tenderness; 
a  slight  febrile  movement  is  no.t  infrequent.  Following  these  symptoms  the 
jaundice  appears.  The  sclerotics  may  be  first  discolored,  the  face  and  neck 
are  also  early  involved;  thence  the  yellow  color  spreads  over  the  whole  body 
including  the  mucous  membranes.  Even  the  perspiration  may  be  tinged. 
In  instances  of  long  standing  the  color  deepens  to  a  brownish  or  greenish- 
yellow.  The  urine  is  dark  reddish-brown  or  dark  green  and  when  shaken 
its  foam  is  of  a  yellow  color.  In  protracted  instances  albumin  and  casts  may 
be  found,  the  latter  often  being  bile  stained. 

Constipation  is  usually  present,  the  stools  are  foul  of  odor  and  light  grayish 
or  clay-colored.     Rarely  there  may  be  diarrhoea. 

Infrequently  the  tears,  saliva  and  milk  are  tinged  with  yellow. 

The  pulse  rate  is  slowed,  at  times  being  even  as  low  as  30  beats  per  minute. 
The  respiration  is  unaffected. 

There  is  often  an  annoying  itching  of  the  skin  and  such  cutaneous  lesions 
as  urticaria,  furunculosis,  lichen  and  xanthelasma,  a  manifestation  consisting 
of  slightly  elevated  yellow  macules  occurring  upon  the  eyelids  and  rarely  upon 
other  parts,  may  be  observed.  In  grave  instances  of  the  affection  ecchymoses 
and  even  large  haemorrhages  may  appear  in  the  skin  and  mucous  membranes. 

Symptoms  referable  to  the  nervous  system  are  common.  The  spirits,  are 
depressed  and  the  patient  may  be  melancholic.  The  temper  is  irritable 
and  headache  and  dizziness  are  common.  Visual  disorders  may  occur, 
objects  may  appear  to  be  of  a  yellow  color,  the  patient  may  see  better  by  a 


468         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

dim  light  or  vision  in  the  dusk  may  be  indistinct.  Marked  and  severe  nervous 
symptoms  occur  in  grave  instances  of  jaundice  but  more  particularly  in  asso- 
ciation with  acute  yellow  atrophy,  carcinoma  and  fatty  degeneration  of  the 
liver  than  in  catarrhal  inflammation  of  the  bile  passages.  These  symptoms 
are  acute  delirium,  convulsions  or  suddenly  appearing  coma.  Usually  there 
are  accompanying  fever,  rapid  pidse  and  prostration,  which  with  the  nervous 
manifestations,  comprise  the  symptom  complex  to  which  the  term  cholcemia 
has  been  applied;  this  condition  is  probably  due  to  the  presence  in  the  blood 
of  some  poisonous  constituent  of  the  bile. 

Physical  examination  may  reveal  the  presence  of  a  more  or  less  enlarged 
and  tender  liver;  sometimes  the  gall-bladder  is  distended  and  palpable. 

The  diagnosis.  Jaundice  occurring  acutely  with  symptoms  of  gastro- 
duodenitis,  a  history  of  dietary  indiscretions  and  in  the  absence  of  manifesta- 
tions suggestive  of  acute  yellow  atrophy,  carcinoma  or  hepatic  cirrhosis  is 
distinctive  of  catarrhal  obstruction  of  the  bile  passages.  The  pigmentation 
of  the  skin  of  Addison's  disease  may  be  mistaken  for  jaundice  but  in  the  former 
condition  the  eyes  are  not  colored  and  the  faeces  are  not  clay-colored.  The 
same  is  true  of  the  cutaneous  discoloration  observed  in  uterine  affections, 
malaria  and  cancer. 

The  prognosis  of  uncomplicated  catarrhal  jaundice  is  uniformly  favorable. 
The  duration  of  the  disease  is  usually  from  10  days  to  8  weeks;  if  the  course 
is  protracted  beyond  this  limit  the  possibility  of  mistaken  diagnosis  must  be 
considered.  A  febrile  movement  and  the  incidence  of  haemorrhages  are 
unfavorable  manifestations. 

Treatment.  The  patient  should  be  kept  in  bed  while  there  remains  any 
elevation  of  temperature  and  while  there  are  active  symptoms  of  gastric  irrita- 
tion. While  there  is  interference  with  the  flow  of  bile  the  food  should  be  such  as 
does  not  need  this  secretion  to  promote  its  digestion  and  assimilation,  conse- 
quently fats  are  to  be  avoided.  Milk,  however,  while  containing  a  certain 
amount  of  fat,  seems  to  be  well  borne,  and  though  it  may  seem  advisable  to 
remove  the  cream,  this  need  not  be  done.  Other  substances  which  are 
allowable  are  egg-albumin  and  meat  broths.  As  the  digestive  irritation 
diminishes  and  the  flow  of  bile  increases  the  diet  may  be  more  liberal  and 
we  may  add  eggs,  fish  and  other  non-irritating  foods.  When  the  bile  stasis 
persists  for  some  weeks  and  a  generous  diet  is  needed  to  maintain  the  patient's 
nutrition  the  fats  should  be  replaced  by  carbohydrate  foods.  In  convalescence 
small  meals  taken  frequently  are  to  be  preferred  to  those  of  large  amount 
at  more  infrequent  intervals.  The  diet  in  any  individual  instance  should  be 
governed  by  the  condition  of  the  stomach  and  intestine,  consequently  it  may  be 
said  that  the  feeding  in  catarrhal  jaundice  after  the  acute  stage  is  passed  is 
that  of  gastro-intestinal  catarrh. 

At   the  beginning  the  bowels  should  be  freely  opened  by  small  repeated 


ACUTE  CATARRHAL  JAUNDICE.  469 

doses  of  calomel — J  grain  (0.016)  every  J  hour  until  6  doses  have  been  taken — 
followed  by  a  saline;  here  we  may  give  the  natural  Carlsbad  salt  in  doses  of 
2  or  3  drachms  (8.0  to  12.0),  Hunyadi,  Apenta  or  any  of  the  similar  laxative 
waters.  During  the  progress  of  the  affection  free  daily  evacuations  should 
be  induced  by  the  administration  of  salines  such  as  magnesium  or  sodium 
sulphate,  sodium  phosphate,  Carlsbad  salts  or  Vichy,  Hunyadi,  Friedrichshall, 
Rubinat  or  Saratoga  Hathorn  waters.  By  this  means  the  catarrhal  process  in 
the  duodenum  is  lessened  and  the  mucus  is  dissolved  from  the  lining  of  this 
viscus.  The  drastic  vegetable  purgatives  should  be  avoided  on  account  of 
their  irritant  properties. 

The  patient's  thirst  may  be  relieved  by  any  of  the  palatable  alkaline  waters 
such  as  Vichy,  and  frequent  draughts  will  aid  in  freeing  the  duodenum  from 
its  accumulated  mucus,  thus  acting  in  connection  with  the  laxatives  suggested 
above. 

In  relieving  the  stasis  of  bile  and  hastening  the  flow  of  this  secretion  no  drug 
is  more  active  than  salicylic  acid  in  doses  of  from  10  to  20  grains  (0.66  to  1.33). 
Calomel,  also,  has  been  suggested  in  this  connection  but  its  cholagogue 
action  is  disputed  in  the  light  of  our  present  knowledge.  Its  effect  is  evidenced 
by  a  return  of  the  stools  and  urine  to  normal  color  rather  than  by  a  disap- 
pearance of  the  jaundice.  High  rectal  enemata  of  ice  water  may  assist  in 
removing  the  plug  of  mucus  from  the  opening  of  the  bile  duct;  their  action  is 
probably  due  to  a  stimulating  effect  upon  peristalsis.  Massage  over  the 
region  of  the  gall-bladder  may  be  employed  in  the  hope  of  stimulating  the  flow 
of  bile  and  the  same  may  be  stated  concerning  the  faradic  current,  which 
should  be  used  in  considerable  strength.  While  not  much  is  to  be  expected 
of  these  latter  measures  their  employment  is,  to  say  the  least,  harmless. 

The  gastric  irritability  may  be  relieved  by  regulation  of  the  diet  and  by  the 
administration  of  sodium  bicarbonate  in  watery  solution  or  in  connection  with 
cerium  oxalate — 20  grains  (1.33)  of  the  former  and  10  grains  (0.66)  of  the 
latter  being  added  to  each  glass  of  milk  that  the  patient  takes.  Plain  water, 
taken  in  considerable  amount  and  as  hot  as  possible,  is  often  effective.  If 
there  is  uncontrollable  vomiting  all  food  should  be  stopped,  the  patient  being 
allowed  to  suck  bits  of  cracked  ice;  small  doses  of  dilute  hydrocyanic  acid 
may  be  effective  in  combating  this  symptom. 

Diarrhoea  is  uncommon  but  if  present  may  be  controlled  by  means  of  bis- 
muth subsalicylate  or  subnitrate  in  the  usual  doses  or  still  better  by  such  intes- 
tinal antiseptics  as  bismuth  naphtholate — gr.  5  (0.33)  three  or  four  times  a 
day — combined  with  an  equal  amount  of  phenyl  salicylate  (salol)  or  2  or  3 
grains  (0.13  to  0.2)  of  resorcinol. 

When  the  symptoms  of  gastro-intestinal  irritation  have  ceased  we  may 
substitute  for  the  remedies  previously  given  for  their  relief  a  bitter  tonic  such 
as  the  following:     I^  acidi  nitrohydrochlorici  diluti,  5vi  (24.0);  fluidextract-'' 


470         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

nucis  vomicae,  fluidextracti  gentiainas,  aa  5i  (4.0);  aquas  cinnamomi  q.s.  ad 
5iv  (120.0).  One  teaspoonful  to  be  taken  in  a  little  water  before  each  meal. 
Instead  of  this  10  minims  (0.66)  of  dilute  hydrochloric  acid  may  be  added 
to  a  tumblerful  of  water  and  drunk  with  the  meals. 

The  pruritus  may  be  reheved  by  warm  baths  to  which  a  pound  (1500.0)  of 
sodium  bicarbonate  has  been  added,  by  lotions  of  i  to  60  phenol,  10  percent, 
menthol  in  albolene,  by  powdering  the  skin  with  talc,  bismuth  subgallate  or 
zinc  stearate  and  by  the  administration  of  calcium  chloride  in  doses  of  from 
15  to  20  grains  (i.o  to  1.33)  2  or  3  times  daily  or  of  a  powder  containing  10 
grains  (0.66)  of  sodium  bromide  and  five  (0.33)  of  antipyrine  at  similar 
intervals. 

In  persistent  instances  of  the  disease  the  patient  will  usually  derive  much 
benefit  from  a  stay  at  one  of  the  spas  such  as  Saratoga  or  Bedford  in  the 
United  States,  Harrogate  in  England  or  Vichy  or  Carlsbad  upon  the  continent. 
Here  the  good  effect  of  the  internal  use  of  the  waters,  of  the  bathing  and  of 
the  systematic  life  will  soon  be  felt. 

Toxic  Jaundice. 

This  type  of  jaundice,  formerly  considered  hasmatogenous  in  origin,  is  now 
held  to  be  the  result  of  biliary  obstruction  caused  by  increased  viscidity  of  the 
bile  accompanied  by  cholangitis. 

Toxaemic  jaundice  is  produced  by  the  following  causes: 

1.  The  action  of  such  poisonous  substances  as  arsenic  and  phosphorus. 

2.  Specific  infectious  diseases  such  as  yellow  fever,  malaria,  enteric  and 
typhus  fevers,  pyaemia,  scarlatina,  etc. 

3.  Obscure  conditions,  probably  of  infectious  origin  such  as  Weil's  disease 
or  acute  febrile  jaundice,  and  acute  yellow  atrophy  of  the  liver. 

The  poisons  are  believed  to  cause  obstruction  in  the  following  way: 
there  is  destruction  of  the  blood  by  haemolysis  which  results  in  the  liberation 
of  haemoglobin  and  an  increased  production  and  excretion  of  bile  pigment ;  the 
bile  becomes  more  viscid  and  produces  a  transient  obstruction  with  reabsorp- 
tion  of  bile  and  consequent  jaundice.  As  the  toxaemia  disappears  the  viscidity 
of  the  bile  becomes  diminished,  the  secretion  flows  more  freely  and  the  jaundice 
disappears. 

The  symptoms  of  toxic  icterus  are  less  marked  than  those  of  the  more  truly 
obstructive  type  of  the  affection;  while  the  skin  may  be  yellowish  the  stools 
are  seldom  clay-colored  and,  although  the  urine  may  be  darkened,  there  is  a 
conspicuous  absence  of  bile  pigment.  In  some  instances  there  are  extremely 
severe  constitutional  symptoms  such  as  high  fever,  great  prostration,  marked 
mental  disturbances,  coma,  anuria  and  haemorrhages  into  the  skin  and  from 
the  mucous  membranes. 


ACUTE    CHOLECYSTITIS.  47 1 

Icterus  Neonatorum. 

Jaundice  is  a  common  manifestation  in  newly-born  infants.  It  occurs  in 
both  a  mild  and  a  severe  type.  The  former  is  quite  common  and  often 
makes  its  appearance  within  2  or  3  days  of  birth.  Its  cause  is  not  definitely 
known  but  it  is  probably  due  to  biliary  stasis  in  the  smaller  bile  ducts.  Certain 
authorities  have  attributed  it  to  the  destruction  of  red  blood  cells  by  haemolysis, 
the  jaundice  resulting  in  the  same  fashion  as  in  toxic  icterus.  The  condition 
is  characterized  by  yellowish  discoloration  of  the  skin,  darkened  urine  and 
light  colored  stools.  There  is  seldom  any  digestive  disturbance  and  the 
symptoms  usually  disappear  within  a  week  or  two. 

The  grave  type  of  jaundice  of  the  newly-born  may  be  the  result  of  con- 
genital absence  of  the  common  or  hepatic  ducts,  congenital  syphilitic  inflam- 
mation of  the  liver  or  of  septic  plilebitis  of  the  umbilical  vein.  The  outcome 
is  usually  fatal. 

Treatment.  The  mild  form  of  infantile  jaundice  needs  no  treatment. 
Treatment  of  the  severe  form  is  fruitless  unless  the  condition  is  due  to  syphil- 
itic hepatitis,  when  anti-luetic  measures  are  indicated. 

ACUTE  CHOLECYSTITIS. 

Synonyms.  Acute  Infectious  Cholecystitis;  Acute  Inflammation  of  the 
Gall-bladder. 

Definition.  An  acute  inflammation  of  the  gall-bladder  resulting  from 
the  invasion  of  pathogenic  micro-organisms. 

.Etiology.  Although  the  presence  of  biliary  calculi  in  the  bladder  itself 
or  in  the  ducts  leading  to  this  structure,  is  an  important  predisposing  cause 
of  infectious  cholecystitis,  the  inflammation  may  occur  in  their  absence. 
The  direct  cause  of  the  affection  is  infection  with  some  one  of  the  pathogenic 
bacteria,  especially  the  streptococcus,  the  staphylococcus,  the  pneumococcus 
and  particularly  the  colon  bacillus  and  the  bacillus  of  enteric  fever.  As  pre- 
disposing factors  other  than  biliary  calculi  all  obstructive  influences,  such  as 
inflammatory  adhesions  or  catarrhal  inflammation  of  the  lining  of  the  cystic 
duct,  must  be  considered  since  they  diminish  the  local  resistance  to  bacterial 
infection. 

Pathology.  This  depends  upon  the  activity  of  the  infective  process.  Usu- 
ally the  gall-bladder  is  distended  and  tense,  its  lining  is  congested  and  its 
cavity  contains  dark  muco-pus,  sanious  pus  or  pus.  Gangrene  with  perfora- 
tion may  take  place,  in  which  case  the  contents  of  the  gall-bladder  is  of  foul 
odor.  The  perforation  may  be  shut  off  by  adhesions  and  form  a  localized 
abscess  cavity  or  it  may  result  in  a  generalized  infection  of  the  peritonaeum. 
Inflammatory  adhesions  to  adjacent  structures,  particularly  the  colon  and 


472         DISEASES   OF    THE    DIGESTIVE    SYSTEM    AND    PERITONiEUM. 

omentum,  are  common.     The  cystic  duct  may  be  occluded  by  an  impacted 
calculus  or  by  inflammatory  swelling  of  its  wall. 

Symptoms.  The  affection  may  first  indicate  its  presence  by  perforation 
but  usually  the  earliest  symptom  to  be  noted  is  pain,  often  sudden  and  parox- 
ysmal, referred  to  the  region  of  the  liver.  In  some  instances  the  pain  is  farther 
to  the  left  than  this  situation  and  it  may  even  be  as  low  as  the  right  iliac  region. 
There  are  early  symptoms  of  gastric  irritation  such  as  nausea  and  vomiting; 
there  is  prostration  with  a  rise  of  temperature  often  accompanied  by  rigors 
and  sweats.  The  pulse  is  usually  accelerated  but  at  times  may  be  extremely 
slow.     Jaundice  is  rare  unless  the  hepatic  or  common  duct  is  involved. 

Palpation  of  the  abdomen  elicits  tenderness,  often  extreme  and  generally 
localized,  but  at  times  in  an  unexpected  situation.  There  is  rigidity  of  the 
abdominal  muscles  and  the  distended  gall-bladder  may  be  felt.  Adhesions 
between  the  intestine  and  the  gall-bladder  may  result  in  the  partial  or 
entire  occlusion  of  the  bowel  with  attendant  symptoms. 

The  diagnosis.  Here  the  history  is  of  great  value,  symptoms  suggestive 
of  cholecystitis  and  yet  resembling  those  of  appendicitis  or  those  of  intestinal 
obstruction  when  occurring  after  pneumonia,  enteric  fever  or  previous  affec- 
tions of  the  biliary  tract,  being  much  less  puzzling  than  when  they  appear  inde- 
pendently. In  the  absence  of  history  it  is  often  very  difl&cult  to  differentiate 
acute  cholecystitis  from  appendicitis,  pancreatitis  and  localized  peritonitis. 
Jaundice  is  more  likely  to  appear  in  pancreatic  disease  but  the  true  nature 
of  the  condition  is  often  not  determined  until  laparotomy  has  been  performed. 

The  prognosis  naturally  depends  upon  the  type  of  infection  and  its  severity; 
the  acute  suppurative  form  is  a  grave  condition  on  account  of  the  probability 
of  perforation  peritonitis,  local  or  general;  in  the  latter  instance  death  is  certain 
unless  operation  is  undertaken. 

Treatment.  The  mild  types  of  the  affection  in  which  there  is  no  distinct 
evidence  of  suppuration  should  be  treated  by  rest  in  bed  and  light  diet.  Sali- 
cylic acid  or  sodium  salicylate,  preferably  the  former,  should  be  given  3 
times  daily  in  doses  of  about  10  grains  (0.66)  in  order  to  increase  the  bile 
flow  and  to  prevent  extension  of  the  inflammatory  process  into  the  ducts. 
The  bowels  should  be  kept  open  by  means  of  mild  laxatives  and  the  pain  may 
be  relieved  by  the  application  of  hot  or  cold  compresses;  morphine  should 
not  be  given  unless  absolutely  necessary  for  it  is  apt  to  obscure  the  symptoms. 
Nausea  and  gastric  irritation  may  be  controlled  by  the  usual  means.  Meth- 
ylthionine  hydrochloride  (methylene  blue)  in  capsules  containing  i  grain 
(0.065)  and  sodium  succinate  in  doses  of  5  grains  (0.33)  have  been  recom- 
mended. 

Upon  the  incidence  of  the  slightest  signs  of  suppuration  immediate  surgical 
interference,  consisting  of  free  incision  and  drainage  of  the  gall-bladder,  is 
indicated. 


CHOLELITHIASIS.  473 

CHOLELITHIASIS. 

Synonyms.     Gall-stone  Disease;  Biliary  Calculus;  Hepatic  Calculus, 

iEtiology.  Biliary  calculi  are  either  (i)  hepatic  in  source,  originating  in 
the  bile  ducts  because  of  a  slow  catarrhal  process  which  results  in  the  secretion 
of  an  albumin  substance,  which  in  combination  with  the  bile  precipitates 
a  bilirubin-calcium  calculus,  or  (2)  are  formed  in  the  gall-bladder  because  of  a 
low  grade  catarrhal  process  which  induces  a  secretion  of  cholesterin  from  the 
mucous  glands  and  ceUs  of  its  walls.  Of  these  the  former  origin  is  by  far 
the  more  frequent.  This  explanation  of  the  source  of  gall-stones  also  accounts 
for  the  fact  that  oftentimes  after  the  performance  of  a  cholecystotomy  gall- 
stones continue  to  be  discharged  from  the  fistula  for  weeks  and  even  months. 
It  also  points  out  why  removal  of  the  gall-bladder  itself  is  not  followed  by  a 
cessation  of  attacks  of  gall-stone  colic. 

The  recognition  of  the  microbic  origin  of  biliary  calculi  dates  only  to  1886. 
In  1897  it  was  clearly  shown  that  the  colon  bacillus  could  be  responsible, 
gaining  access  by  either  (i)  the  intestinal  canal  by  way  of  the  common  duct, 
or  (2)  through  the  portal  vein.  Although  jaundice  as  a  sequel  to  enteric 
fever  had  been  observed  as  early  as  1826,  it  was  not  until  1889  that  the  typhoid 
bacillus  was  recognized  as  a  causative  factor  entering  by  way  of  (i)  the  portal 
vein,  (2)  the  hepatic  artery,  or  (3)  the  common  duct.  That  other  infections 
are  also  directly  responsible  has  been  shown,  for  low  grade  cholecystitides 
have  been  observed  after  acute  infectious  pneumonia,  acute  rheumatic  poly- 
arthritis and  chronic  tuberculosis.  That  gall-stones  do  not  oftener  result, 
the  explanation  may  be  that  acute  suppurative  inflammations  of  the  bile 
ducts  or  gall-bladder  do  not  result  in  calculi  but  rather  these  are  due  to  atten- 
uated infections. 

The  mechanical  causes  of  gall-stones:  (i)  Foreign  bodies  if  sterile  are 
harmless.  If  they  produce  stagnation  they  favor  catarrhal  processes  and  so 
give  opportunity  for  infection.  (2)  Stagnation  of  bile  in  itself  does  not 
favor  calculus  formation  but  since  stagnation  favors  infection  it  may  lead 
directly  to  the  formation  of  stone.  (3)  Chronic  venous  congestion  of  the 
portal  system  is  a  more  potent  cause  of  the  production  of  gall-stones  since  it  is 
the  great  underlying  cause  of  cholelithiasis.  The  congestion  of  the  portal 
circulation  may  occur  as  a  result  of  (a)  chronic  heart  disease — especially 
mitral  obstruction — (6)  chronic  pulmonary  disease — particularly  chronic 
emphysema  and  chronic  interstitial  pneumonia — (c)  intestinal  catarrhs  due 
to  the  abuse  of  alcohol,  gluttony  and  rarely  to  the  excessive  employment  of 
vigorous  purgatives;  a  more  common  cause  of  intestinal  catarrh  than  any 
of  the  preceding  is  constipation  which  not  only  predisposes  to  infection  but 
offers  opportunity  for  auto-intoxication.  (4)  Of  mechanical  causes,  not 
hitherto  enumerated,  worthy  of  mention  are  (a)  pregnancy,  (b)  visceroptosis — 


474         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Gldnard's  disease — (c)  over-fitted  hepatic  flexure  of  the  colon,  (d)  displace- 
ments of  the  duodenum,  all  of  which  may  cause  biliary  stasis  and,  as  above 
mentioned,  predispose  to  the  production  of  gall-stones.  (5)  Of  extraneous 
causes  anything  which  reduces  the  vitality  of  the  individual  such  as  (a)  anxiety, 
(b)  bodily  exhaustion  from  excessive  physical  or  manual  labor,  or  (c)  wasting 
diseases  may  be  mentioned. 

Gall-stones  may  be  single  or  multiple;  they  are  usually  brownish  in  color, 
rounded,  oval  or  polyhedral  in  shape.  In  size  they  vary  from  that  of  a  millet 
seed  to  even  5  inches  (12  cm.)  in  length.  The  small  calculi  are  often  very 
numerous,  thousands  having  been  found  in  a  single  gall-bladder.  A  number 
of  stones  impacted  together  become  faceted  as  a  result  of  their  pressure  upon 
one  another.  Irregular  (mulberry)  calculi  are  sometimes  found.  Section  of 
a  gall-stone  reveals  a  nucleus  usually  consisting  of  bile  pigment  or  more 
rarelv  a  foreign  body.  Collections  of  micro-organisms  are  said  to  have  been 
found  at  the  nucleus  of  certain  kinds  of  gall-stones.  Chemically  the  calculi 
consist  chiefly  (70  to  80  percent.)  of  cholesterin  arranged  concentrically.  In 
some  instances  the  stone  is  composed  wholly  of  this  substance,  usually, 
however,  other  constituents  such  as  bile  pigment,  calcium  carbonate,  magne- 
sium salts,  fatty  acids,  organic  matter  and  traces  of  copper  and  iron,  are  found. 
Rarely  calculi  may  be  composed  almost  wholly  of  bilirubin-calcium.  The 
most  common  type  of  gall-stone  is  the  mixed  cholesterin  calculus;  this  is 
yellow,  brown  or  white  and  is  generally  faceted.  Mixed  bilirubin  and 
cholesterin  stones  consist  of  a  nucleus  of  the  latter  substance  covered  by  dark 
brown  material. 

Calculi  are  formed  in  the  gall-bladder  where  they  may  exist,  as  stated,  in 
enormous  number;  they  may  also  be  formed  in  any  part  of  the  biliary  tract 
either  without  or  within  the  substance  of  the  liver.  Lodgment  of  calculi 
often  takes  place  in  the  cystic  and  common  ducts.  In  the  latter  the  point 
of  lodgment  is  usually  in  the  ampulla  of  Vater;  dilatation  of  the  duct  behind 
the  obstruction  may  take  place.  Obstruction  of  the  cystic  duct,  if  permanent, 
results  in  dilatation  of  the  gall-bladder,  which  may  be  so  distended  as  to  be 
mistaken  for  an  ovarian  cyst.  The  contents  of  the  bladder  is  a  colorless, 
sometimes  viscid,  fluid  of  neutral  or  alkaline  reaction  and  contains  albumin. 
The  gall-bladder  which  contains  calculi  is  not  enlarged  except  in  so  far  as  the 
contained  stones  increase  its  size  (Courvoisier's  law).  Ulceration  or  suppu- 
ration may  result  from  the  presence  of  a  calculus  and  rupture  may  take  place 
into  any  adjoining  structure. 

Symptoms.  In  many  instances  the  presence  of  biliary  calculi  causes  no 
symptoms  as  is  shown  by  the  facts  that  post  mortem  records  prove  that  from 
6  to  10  percent,  of  all  cadavers  evidence  the  existence  of  gall-stones,  while  not 
more  than  i  person  in  20  of  those  who  carry  calculi  becomes  aware  of  their 
presence  through  any  symptoms  which  may  result  from  them. 


CHOLELITHIASIS.  475 

The  manifestations  of  the  presence  of  gall-stones  may  be  considered  undeK 
several  headings: 

1.  Biliary  colic  is  due  to  acute  impaction  resulting  during  the  passage  of 
stones  through  the  larger  bile  ducts.  The  passage  of  the  calculus  usually 
gives  rise  to  severe  attacks  of  pain  which  is  sudden  in  onset  and  referred  to 
the  epigastrium  or  right  hypochondrium  whence  it  may  radiate  to  the  right 
shoulder  or  to  any  part  of  the  abdomen.  The  pain  is  excruciating  and  lan- 
cinating in  character  and  may  cause  syncope.  The  liver  may  be  enlarged, 
tenderness  is  usually  present  and  the  gall-bladder  may  be  palpable;  there  is 
abdominal  rigidity;  nausea  and  vomiting  occur.  There  are  often  chills;  the 
temperature  rises  to  102°  to  103°  F.  (38.9°  to  39.5°  C.)  or  even  higher.  The 
fever  may  be  intermittent  in  type  but  is  more  apt  to  assume  this  form  in  pro- 
tracted obstruction  due  to  chronic  impaction  of  calculi  (intermittent  hepatic 
fever).     There  may  be  circulatory  depression  with  rapid  and  feeble  pulse. 

There  is  usually  splenic  enlargement  and,  if  the  attack  is  prolonged, 
jaundice  is  likely  to  appear,  particularly  if  the  stone  becomes  impacted  in  the 
opening  of  the  common  duct.  The  paroxsym  of  colic  varies  in  duration 
from  a  few  hours  to  a  week  or  more;  it  may  recur  at  intervals,  the  symptoms 
ultimately  disappearing  with  the  passage  of  the  calculus. 

Rupture  may  take  place  at  the  site  of  the  obstruction  with  death  from 
peritonitis  as  a  result;  convulsions  have  been  observed. 

The  diagnosis  is  seldom  difficult;  the  site  of  the  pain  is  characteristic  and 
its  occurrence  with  tenderness  over  the  liver,  a  chill  and  jaundice  leaves 
hardly  room  for  doubt.  The  history  is  often  of  marked  assistance.  Renal 
colic  is  accompanied  by  pain  radiating  downward  to  the  groin  or  testicle  and 
by  bloody  urine  which  often  contains  pus  cells.  Appendicitis,  while  it  may  be 
associated  with  pains  similar  to  those  of  hepatic  colic,  is  not  attended  with 
jaundice.  The  pseudo-biliary  colic  which  may  occur  in  women  may  be  differ- 
entiated by  the  absence  of  jaundice  and  the  presence  of  nervous  symptoms 
of  various  kinds.  Finding  calculi  in  the  faecal  discharges  is  confirmatory 
of  the  diagnosis  of  gall-stone  colic.  A  search  for  these  should  always  be  made 
in  suspicious  instances  during  the  three  or  four  days  following  an  attack.  The 
stools  should  be  washed  upon  a  fine  seive  until  all  soluble  matter  has  been 
flushed  through. 

The  prognosis  as  to  recovery  from  the  paroxysm  is  favorable,  death  from 
syncope,  perforation  or  convulsions  being  a  rare  occurrence. 

2.  Chronic  Impacted  Gall-stone:  During  the  passage  of  a  calculus  through 
the  ducts  toward  the  duodenum  impaction  not  infrequently  takes  place. 
The  impaction  may  occur, 

a.  In  the  Cystic  Duct. 

Symptoms.  These  may  resemble  in  greater  or  less  degree  those  of  acute  im- 
paction with  added  dilatation  of  the  gall-bladder  {hydrops  vesica  fellece).     The 


476         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM 

dilatation  is  the  result  of  the  accumulation  of  the  exudation  due  to  inflammation 
of  the  lining  mucous  membrane  plus  the  bile  that  was  present  when  the 
obstruction  took  place.  The  increase  in  the  size  of  the  gall-bladder  may  be 
great  and  the  condition  has  been  mistaken  for  ovarian  cyst.  On  opening  the 
gall-bladder  the  fluid  contents  is  found  to  consist  chiefly  of  mucus  of  alkaline 
or  neutral  reaction.  Jaundice  may  not  be  present  and,  while  at  times  the  dis- 
tended gall-bladder  may  not  be  palpable,  it  may  often  be  felt  as  a  rounded  or 
gom^d-shaped  fluctuating  tumor  projecting  downward  or  to  the  left  toward 
the  mid-line  of  the  abdomen.  If  the  abdominal  wall  is  thin  and  relaxed 
crepitus  due  to  the  presence  of  calculi  may  be  demonstrated. 

b.  Impaction  in  the  Common  Bile  Dud. 

Symptoms.  The  obstruction  may  be  due  to  one  or  several  stones  firmly 
fixed  in  any  portion  of  the  duct  or  in  the  ampulla  of  Vater.  If  a  considerable 
number  of  calculi  is  present  these  may  fill  the  hepatic  and  cystic  ducts  as  well. 
Dilatation  of  the  gall-bladder  to  a  slight  degree  may  be  observed  but  is  by 
no  means  constant.  Cholangitis  is  a  usual  sequence  and  may  be  either  of 
chronic  catarrhal  or  of  suppurative  type. 

In  chronic  catarrhal  cholangitis  due  to  permanent  obstruction  there  is 
marked  and  permanent  jaundice,  nausea  and  vomiting  may  be  present  and 
the  condition  may  be  differentiated  from  obstruction  due  to  neoplasm  by  the 
history  of  previous  colic,  the  pain,  which  may  be  intermittent,  and  the  absence 
of  increase  in  the  size  of  the  gall-bladder.  A  limpid  mucoid  fluid  is  usually 
found  in  the  distended  ducts. 

Naunyn  mentions  the  following  diagnostic  signs  of  calculus  in  the  common 
duct:  "  (i)  The  continuous  or  occasional  presence  of  bile  in  the  faeces;  (2) 
distinct  variations  in  the  intensity  of  the  jaundice;  (3)  normal  size  or  only 
slight  enlargement  of  the  liver;  (4)  absence  of  distention  of  the  gall-bladder; 
(5)  enlargement  of  the  spleen;  (6)  absence  of  ascites;  (7)  presence  of  febrile 
disturbance,  and  (8)  duration  of  the  jaundice  for  more  than  a  year." 

Incomplete  obstruction  with  infective  cholangitis  is  usually  evidenced  by 
rather  typical  symptoms  but  the  causative  condition,  which  may  be  either 
a  number  of  stones  in  the  common  duct,  one  of  which  is  movable,  or  the  so- 
called  ball-valve  calculus  which  is  most  often  found  in  the  ampulla  of  Vater, 
but  sometimes  in  the  common  duct;  this  may  exist  without  causing  any 
suspicion  that  gall-stones  are  present.  The  ball- valve  calculus  evidenced 
its  presence  by  a  rather  characteristic  train  of  symptoms  which  consists  of  a 
febrile  movement  occurring  in  malaria-like  paroxysms  and  associated  with 
rigors  and  sweats  (intermittent  hepatic  fever)  and  persistent  jaundice  of  varying 
degree  but  which  is  intensified  after  each  febrile  paroxysm,  this  last  often 
being  accompanied  by  the  manifestations  of  gastric  irritation  and  hepatic 
pain.  Such  manifestations  may  appear  from  time  to  time  during  a  period 
of  several  years  without  the  incidence  of  suppurative  inflammation.     The 


CHOLELITHIASIS.  477 

rises  in  temperature  are  probably  due  to  some  mild  infection,  possibly  the 
result  of  the  presence  of  the  bacillus  coli  communis  although  they  have  also 
been  explained  upon  the  ground  of  irritation.  In  the  diagnosis  of  common 
duct  obstruction  it  is  to  be  remembered  that  this  condition,  when  due  to  stone, 
does  not  give  rise  to  dilatation  of  the  gall-bladder.  This  rule  (Courvois- 
ier's  law)  is  valid  in  about  go  percent,  of  cases  but  the  following  exceptions 
have  been  mentioned  by  Moynihan:  "  (i)  When  there  is  a  stone  or  a  stric- 
ture in  the  cystic  duct  causing  hydrops  or  empysema,  together  with  the  acute 
impaction  of  a  stone  in  the  common  duct;  (2)  where  there  is  a  stone  in  the 
cystic,  duct  pressing  upon  the  common  duct;  (3)  when  there  is  distention 
of  the  gall-bladder  by  an  acute  inflammatory  process,  with  obstruction  of 
the  common  duct  by  stone;  (4)  where  there  is  chronic  induration  of  the  head 
of  the  pancreas,  with  a  stone  in  the  common  duct;  (5)  where  there  is 
malignant  disease  of  the  common  duct  at  any  part  of  its  course,  or  cancer 
of  the  head  of  the  pancreas,  and  a  chronic  sclerosing  cholecystitis." 

Suppurative  cholangitis  is  evidenced  by  a  fever  of  more  distinctly  septic 
character  than  that  just  described ;  the  remissions  are  less  distinct  and  shorter  and 
with  the  paroxysms  there  is  no  augmentation  of  the  jaundice.  There  are  hepatic 
tenderness  and  enlargement  and  the  suppurative  process  often  extends  into  the 
ducts  in  the  liver,  causing  abscess,  as  well  as  into  the  gall-bladder.  The  evolution 
of  the  condition  is  shorter  than  that  of  infective  cholangitis  and  death  is  the 
usual  termination.  Post  mortem,  the  mucous  lining  of  the  ducts  is  found  thick- 
ened and  perhaps  ulcerated;  abscess  may  be  present  in  the  liver  substance  and 
pus  may  distend  the  gall-bladder.     Rupture  of  this  viscus  has  been  observed. 

Remote  effects  of  impaction  of  gall-stones:  Biliary  fistulas  are  not  infre- 
quently observed.  The  fistulous  opening  most  commonly  met  is  that  in 
which  external  perforation  through  the  skin  has  taken  place j  the  most  usual 
situations  are  the  right  hypochondriac  and  the  umbilical  regions.  Gall-stones 
may  be  discharged  and  recovery,  even  without  operation,  may  follow.  Ulcera- 
tive perforation  may  take  place  into  the  peritonaeal  cavity  with  localized 
abscess  formation,  general  peritonitis  or  retro-peritonseal  perforation.  Com- 
munications between  the  bile  ducts  themselves,  the  gall-bladder  or  the  intes- 
tine are  common,  the  usual  exit  of  large  calculi  being  through  a  colonic  per- 
foration. Fistulous  openings  into  the  portal  vein  and  stomach  are  rare. 
Perforations  into  the  pleiu-a,  lungs  and  urinary  passages  have  been  observed. 

Septic  cholecystitis,  empyasma  of  the  gall-bladder,  may  follow  the  suppura- 
tive cholangitis  of  impacted  stone.  Calcification  of  the  mucous  lining  or 
of  the  entire  wall  of  the  bladder  may  supervene  upon  purulent  inflammations 
and  atrophy  of  the  viscus  may  take  place  after  the  excessive  dilation  of  hydrops. 
Suppurative  pylephlebitis  or  hepatic  abscess  may  result  from  purulent  cholan- 
gitis. Intestinal  obstruction  due  to  biliary  calculus,  the  stoppage  being  most 
usually  observed  at  some  point  in  the  ileum,  is  not  very  uncommon. 


478         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Of  the  other  results  of  gall-stone  disease  the  following  should  be  mentioned: 

1.  Diabetes  mellitus.  Gall-stone  impacted  in  the  lower  end  of  the  common 
duct  or  in  the  diverticulum  of  Vater  may  lead  to  infection,  as  previously  stated, 
chronic  interstitial  pancreatitis  and  destruction  of  the  islands  of  Langerhans. 

2.  Glycosuria  from  the  same  course  of  events  with  interference  with  the  func- 
tions of  the  islands  of  Langerhans.  3.  Chronic  interstitial  pancreatitis  with 
amylaceous  or  lipatic  indigestion  and  malnutrition.  4.  Gall-stone  impacted 
in  the  duodenum  allowing  penetration  of  bile  into  the  duct  of  Wirsung  with 
haemorrhagic  pancreatitis. 

The  diagnosis  of  the  condition  of  intermittent  hepatic  fever  is  usually 
not  difficult,  its  peculiar  febrile  movement  with  rigors,  sweats  and  jaundice 
being  characteristic.  Cancer  of  the  gaU-bladder  is  not  associated  with  a 
rise  in  temperature,  is  characterized  by  greater  tenderness  and  more  rapid 
emaciation.  The  use  of  the  aspirating  needle  is  quite  justifiable  as  a  means 
of  differentiation. 

In  making  a  diagnosis  of  gall-stone  disease  the  frequency  of  biliary  calculi 
in  elderly  persons  as  a  result  of  senile  atrophy  of  the  smooth  muscle  tissue  in 
the  walls  of  the  gall  ducts  and  bladder,  should  not  be  forgotten. 

The  Ronigen  ray  is  much  less  efficient  as  an  aid  in  the  diagnosis  of  hepatic 
calculi  than  in  that  of  renal  or  ureteral  stone.  Plates  showing  gall-stones 
have  been  obtained  but  the  chance  of  successful  demonstration  of  a  calculus 
is  small,  the  material  of  which  most  of  these  are  formed  offering  little  obstruction 
to  the  ray.  Cholesterin  stones  appear  to  be  transparent  to  the  X-light;  those 
containing  calcium  carbonate  are  much  more  likely  to  throw  a  shadow  on  the 
plate.  The  proper  position  in  which  to  place  the  patient  who  is  being  radio- 
graphed for  gall-stone  is  face  downward  upon  the  plate,  the  body  being  bent 
backward  by  placing  supports  under  the  thorax  and  pelvis,  while  the  tube 
is  placed  a  little  to  the  right  of  the  median  line  opposite  a  point  a  little  below 
the  level  of  the  free  border  of  the  liver. 

Treatment.  Surgery  has  a  distinct  place  in  the  treatment  of  gall-stones 
but  the  treatment  of  gall-stone  disease  may  with  truth  be  said  to  be  entirely 
medical.  Operative  measures  are  adapted  only  to  gall-stones  of  gall-bladder 
origin  and  then  only  under  conditions  which  demand  mechanical  relief. 
Upon  consideration  of  post  mortem  records  it  is  seen  that  from  6  to  10  percent, 
of  all  cadavers  show  the  presence  of  biliary  calculi  and  when  it  is  shown  that 
not  more  than  i  person  in  20  of  those  who  harbor  gall-stones  becomes  aware 
of  their  presence  as  evidenced  by  symptoms,  in  many  instances  insufficient 
to  require  operation,  it  is  readily  demonstrable  that  the  field  of  surgery  is 
decidedly  limited,  although  of  great  importance  in  selected  patients.  Keeping 
these  facts  in  mind,  and  remembering  the  distinction  between  gall-stone  disease 
and  gall-stones,  more  will  be  expected  of  the  internalist  and  fewer  disappoint- 
ments will  be  attributed  to  the  failure  of  surgery. 


CHOLELITHIASIS.  479 

The  treatment  of  the  microbic  causes  of  bihary  calculi  is  that  of  the  re- 
sponsible infection  itself  and  the  limitation  of  opportunities  for  entrance  of 
the  infectious  agent.  The  management  of  the  congestive  disorders  referable 
to  the  heart,  lungs,  etc.,  which  predispose  to  the  formation  of  gall-stones  and 
that  of  the  mechanical  conditions,  such  as  pregnancy  and  visceral  displace- 
ments, need  not  be  dealt  with  here.  The  proper  treatment  of  the  foregoing 
states  will  accomplish  much  in  the  prophylaxis  of  gall-stone  disease. 

Aside  from  the  measures  indicated  in  the  relief  of  an  acute  attack  of  biliary 
colic  the  treatment  should  be  based  upon  the  general  conditions  mentioned 
in  the  immediately  preceding  paragraph.  The  administration  of  olive  oil 
by  the  mouth  for  the  acute  paroxysm  and  for  the  other  phases  of  the  disease, 
even  in  those  instances  in  which  it  is  tolerated  in  sufficiently  large  amounts 
and  for  long  periods  of  time,  has  utterly  failed  to  produce  even  relief.  Oper- 
ative procedures  during  an  attack,  theoretically  so  clearly  indicated  for  an 
impending  suppurative  cholecystitis,  have  almost  uniformly  resulted  in  death 
so  far  as  the  author's  observation  goes. 

It  has  become  apparent  that  the  important  feature  of  the  treatment  of  gall- 
stone disease  is  the  regulation  of  congestions  and  inflammations  in  the  portal 
system  and  dependent  organs,  and  in  local  antiseptics.  The  spa  treatment 
appeals  to  many.  Success  is  based  upon  the  fact  that  at  the  resort  the  patient's 
habits  of  life  are  regulated,  the  diet  is  controlled  and  the  use  of  the  salines 
diminishes  congestions  and  inflammations  in  the  portal  area.  Of  these  Neu- 
enahr,  Kissingen,  Vichy,  in  Europe,  Bedford,  Sharon  and  Las  Vegas  in  the 
United  States,  are  preferred.  Carlsbad  has  the  advantages  of  many  and 
varied  attractions  but  on  account  of  these  it  is  difficult  to  induce  patients 
to  steadfastly  and  seriously  attend  to  the  business  of  getting  well;  because 
of  this  fact,  even  though  the  waters  of  this  resort  are  preferable  to  those  of 
many  others,  a  sojourn  at  this  spa  is  often  of  little  benefit. 

Within  recent  years  it  has  become  possible  to  obtain  practically  as  good 
results  at  home  as  at  the  water  cures  by  means  of  the  subjoined  regime  honestly 
followed:  i.  Diet:  This  should  be  mixed,  for  vegetable  food  produces  a 
smaller  amount  of  bile  acids,  and  saccharine  or  fatty  foods  give  rise  to  intes- 
tinal fermentation.  The  meals  shoiild  be  limited  in  amount,  taken  at  fre- 
quent intervals  to  ensure  constant  flow  of  bile,  with  plenty  of  plain  or  feebly 
mineralized  water  before  each  repast.  Alcohol  is  prohibited.  2.  Exercise, 
especially  in  the  open  air,  is  important. .  3.  Cholagogues:  With  the  excep- 
tion of  salicylic  acid  and  certain  salts,  of  bile  itself  and  especially  of  salts  of 
the  bile  acids,  it  is  doubtful  if  the  drugs  usually  so  designated  are  more  than 
temporarily  effective.  As  for  salicylic  acid  there  is  no  doubt  as  to  its  chola- 
gogue  properties,  that  it  is  excreted  in  the  bile  and  thus  disinfects  the  bile 
passages.  No  advantage  is  possessed  by  sodium  salicylate  given  in  con- 
junction with  sodium  bicarbonate  or  sodium  benzoate.     Salicylic  acid  is  pref- 


480         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

erable  not  only  on  account  of  its  cholagogue  properties  but  because  it  is  a 
biliary  and  intestinal  disinfectant  as  well  (which  the  salicylates  are  not) 
and  thus  diminishes  intestinal  catarrh.  The  bile  acids  in  intestinal  putre- 
faction are  believed  to  be  chemical  antiseptics,  physiological  cholagogues 
and  fat  emulsifiers.  In  hepatic  insufficiency  they  render  the  bile  less  viscid 
and  cause  an  increase  of  normal  bile  acids;  in  gall-stone  they  may  be  preventive 
and,  by  causing  a  copious  outpouring  of  thin  bile,  may  to  some  extent,  prevent 
bacterial  invasion  of  the  gall-bladder  and  hepatic  duct  and  at  the  same  time, 
favor  drainage  of  the  bile  channels.  The  use  of  bile  acids  and  their  salts  is 
more  scientific  than  the  administration  of  bile  itself  because  they  are  the 
physiologically  active  principle  of  this  substance,  and  any  danger  from  the 
introduction  of  poisonous  bodies  from  the  bile,  which  really  is  an  excretion, 
is  thus  avoided.  Of  all  the  preparations  Sodium  glycocholate,  in  ^  to  3  grain 
(0.032  to  0.2)  doses  as  frequently  as  is  necessary,  is  the  best.  Both  bile  and 
its  salts  are,  however,  uncertain  in  action. 

Acid  sodium  oleate,  like  salicylic  acid,  is  excreted  by  the  epithelium  of  the 
bile  ducts  and  so  assists  in  disinfection.  Phenolphthalein,  although  a  phenol 
derivative,  does  not  dissociate  in  the  intestine  to  any  appreciable  extent ;  this 
drug  continues  its  antiseptic  effect  through  the  length  of  the  intestinal  tract. 
If  the  acid  sodium  oleate  is  carefully  prepared  and  is  combined  in  a  pill  with 
salicylic  acid  obtained  from  natural  sources,  ij  grains  (o.i),  phenolphthalein 
I  grain  (0.065),  ^^'^  menthol,  which  is  a  carminative,  acts  as  an  intestinal 
antiseptic,  increases  peristalsis  and  allays  nausea,  \  grain  (0.016)  we  possess 
a  very  efficient  means  of  combating  gall-stone  disease.  This  combination 
is  best  prescribed,  on  account  of  the  difficulty  of  obtaining  the  proper  sodium 
oleate  and  of  manufacture,  as  probilin  pills;  4  to  8  pills  should  be  taken  daily 
in  a  full  glass  of  hot  water.  Following  this  medication  the  elimination  of 
gall-stones  of  the  hepatic  variety  is  generally  rapid.  That  the  process  may  be 
painless  is  best  achieved  by  the  administration  of  amyl  valerate,  15  minims 
(i.o)  in  capsvile  two  hours  before  breakfast  and  after  supper. 

In  the  treatment  of  gall-stone  disease  we  should  consider  that  we  are  con- 
fronted by  an  affection  which  is  not  purely  due  to  the  presence  of  a  foreign  ^ 
body  but  which  is  primarily  a  hepatic  disorder.  The  removal  of  the  calculi 
is  of  little  moment  for  even  when  this  has  been  accomplished  by  surgical 
means  the  patient  is  but  at  the  commencement  of  his  treatment,  the  object 
of  which  is  to  remove  the  cause  of  the  disease,  a  problem  which  is  purely 
medical.  The  congestions  and  inflammations  in  the  portal  area  require 
treatment  and  the  correction  of  these  and  of  the  infectious  catarrhs  of  the 
bile  ducts  and  gall-bladder  and  of  the  faulty  bile  formation  in  the  liver  is  a 
matter  which  is  distinctly  within  the  province  of  the  physician. 

Biliary  colic  with  its  agonizing  pain  often  needs  the  hypodermatic  admin- 
istration of  morphine  for  its  relief;  the  patient  may  be  kept  lightly  under  the 


NEOPLASMS    OF    THE    GALL-BLADDER.  481 

influence  of  chloroform  given  by  inhalation  until  the  effect  of  the  morphine 
is  evident.  Amyl  valerate  in  15  minim  (i.o)  capsules  repeated  every  4  or 
5  hours  may  prove  effective  and  should  always  be  given  in  preference  to  any 
opium  derivative.  It  should  be  hardly  necessary  to  state  that  the  hj'po- 
dermic  syringe  should  never  be  given  to  a  patient.  Antipyrine  given  early  in 
the  paroxysm  may  prove  useful  and  hot  applications  to  the  hepatic  region 
and  hot  baths  are  sometimes  efficient  in  aiding  the  relief  of  the  pain. 
Gastric  lavage  has  been  suggested  and  may  assist  in  the  control  of  the 
nausea  and  vomiting;  these  latter,  however,  usually  stop  with  the  cessation 
of  the  coHc.  In  mild  attacks  8  minims  (0.5)  of  tincture  of  belladonna  in  a 
drachm  (4.0)  of  spirit  of  chloroform  may  lessen  the  pain. 

The  surgical  treatment  of  gaU-stones,  as  previously  asserted,  should  be 
confined  to  those  instances  of  the  disease  in  which  mechanical  removal  of  the 
foreign  body  is  necessary,  the  procedure  in  each  case  being  adapted  to  the 
patient  in  hand.  It  is  difficult  to  see  how  operation  can  do  more  than  relieve 
the  condition  present  at  the  time  of  the  undertaking  for  even  removal  of  the 
gaU-bladder  in  Mo  can  hardly  prevent  the  further  formation  of  calculi  in 
the  bile  ducts. 

Ulceration  of  a  gall-stone  through  the  wall  of  the  bladder  or  of  the  bile  ducts 
with  acute  symptoms  such  as  those  of  peritonitis,  of  course,  demands  imme- 
diate laparotomy. 

NEOPLASMS  OF  THE  GALL-BLADDER. 

Cancer  of  the  gaU-bladder  is  infrequent;  columnar  or  spheroidal-celled 
carcinoma  is  the  usual  type.  It  is  more  frequent  in  men  than  in  women  and 
is  more  often  primary,  the  fundus  being  first  involved.  Secondary  carcinoma 
which  has  spread  from  grovrths  of  adjacent  organs  by  contiguity  has  been 
observed  and  involvement  of  neighboring  structures  in  primary  cancer  of  the 
gall-bladder  also  occurs.  In  a  very  large  majority  of  primary  cancers  gall- 
stones are  present,  the  latter  being  considered  as  cause  of  the  former,  probably 
as  a  result  of  irritation;  the  calculi  have  also  been  held  to  be  a  result  of  the 
neoplasm,  the  growth  causing  changes  in  the  bile  which  favor  their  formation. 

Symptoms.  Jaundice  occurs  with  involvement  of  the  common  or  the 
cystic  duct  but  not  unless  these  structures  are  affected.  Other  symptoms 
are  nausea  and  vomiting,  haematemesis,  melsena,  pain  and  oedema  due  to 
pressure.  The  pain  is  often  paroxysmal  and  tenderness  is  frequently  asso- 
ciated with  it.     Cancerous  cachexia  may  supervene. 

A  dense  and  hard  tumor  is  palpable  in  the  region  of  the  gall-bladder  and 
when  large,  as  often  occurs  as  a  result  of  dilatation  of  the  organ  or  involvement 
of  neighboring  structures  in  the  growth,  extends  downward  and  toward  the 
mid-line  of  the  abdomen. 

Treatment.  Medical  treatment  is  palliative  only.  The  pain  may  be 
31 


482         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

relieved  by  morphine  or  other  less  potent  analgesics;  the  nausea  and  vomiting 
may  be  controlled  by  gastric  sedatives  such  as  menthol,  cerium  oxalate,  dilute 
hydrocyanic  acid,  etc. ;  the  bowels  should  be  kept  open  by  means  of  mild  laxa- 
tives and  if  intestinal  fermentation  exists  the  usual  means  should  be  employed 
in  its  relief. 

In  order  to  be  curative  operation  should  be  undertaken  as  early  as  possible 
and  before  there  is  cancerous  involvement  of  other  organs.  Post-operative 
haemorrhage  is  frequent  and  is  often  responsible  for  death,  consequently 
surgical  measures  should  be  preceded  for  2  or  3  days  by  the  administration 
of  calcium  lactate  or  chloride  20  grains  (1.33)  3  times  daily. 

NEOPLASMS  OF  THE  GALL  DUCTS. 

As  is  the  case  with  malignant  tumor  of  the  gall-bladder,  carcinoma  is  the 
only  type  of  growth  which  affects  the  gall  ducts.  The  condition  is  rare  and 
may  be  either  primary  or  secondary.  In  the  latter  instance  the  primary 
tumor  is  usually  in  the  gall-bladder  or  in  the  liver  itself.  Jaundice  is  an  early 
symptom;  it  is  persistent  and  usually  extreme;  the  development  of  cachexia 
is  rapid.  The  gall-bladder  is  enlarged  and  may  rupture.  Pain  and  tenderness 
are  generally  present.  The  diagnosis  is  difficult  and  often  impossible  without 
exploratory  incision.  Gall-stones  may  be  present,  as  in  carcinoma  of  the 
gall-bladder,  and,  as  in  this  condition,  have  been  held  to  be  both  the  cause  and 
the  result  of  the  cancerous  growth. 

Treatment.  The  medical  treatment  is  identical  with  that  of  carcinoma 
of  the  gall-bladder.  The  itching,  which  is  frequently  associated  with  the 
intense  jaundice,  may  be  relieved  by  weak  phenol  lotions  or  by  means 
of  a  powder  composed  of  an  ounce  (30.0)  of  starch,  a  half  ounce  (15.0)  of 
zinc  oxide  and  i^  drachms  (6.0)  of  camphor. 

Operative  treatment  is  difficult  but  it  may  be  possible  to  remove  the  seat  of 
the  disease  in  certain  instances;  recurrence  after  operation  is  not  infrequent. 
Carcinoma  of  the  ampulla  of  Vater  and  of  the  duodenal  papilla  has  been 
removed,  the  divided  end  of  the  common  duct  being  implanted  into  a  healthy 
part  of  the  duodenum.  , 

STENOSIS  OF  THE  GALL  DUCTS. 

Occlusion  of  the  gall  ducts  may  result  from  cicatrization  of  an  ulcer  due  to  a 
calculus;  syphilis  may  be  a  cause  in  some  instances;  foreign  bodies  may  also 
reach  the  ducts  through  the  duodenum  and  cause  obstruction.  Occlusion 
due  to  the  presence  of  the  ascaris  lumbricoides,  to  the  echinococcus  or  to 
liver  flukes  may  occur  but  is  rare.  Obstruction  also  may  follow  pressure 
from  without  which  may  be  due  to  enlarged  lymph  glands  at  the  hilum 
of  the  liver  or  to  tumors  of  neighboring  parts.  Congenital  obliteration  of  the 
gall  ducts  has  been  observed  and  is  always  fatal. 


ACUTE    PANCREATITIS.  483 

Symptoms.  There  is  early  enlargement  of  the  liver  with  the  symptoms 
of  obstructive  jaundice.  Later  the  liver  may  become  small  and  is  usually 
found  to  be  cirrhotic.  Complete  permanent  occlusion  is  fatal  either  from 
the  condition  itself  or  from  the  causative  lesion.  Patients  with  partial 
stenosis  may  live,  continuously  jaundiced,  for  years. 

In  congenital  obliteration  haemorrhages,  especially  from  the  umbilicus, 
are  prone  to  occur.  There  is  increase  of  the  interstitial  connective  tissue 
of  the  liver  and  the  spleen  is  increased  in  size. 

Treatment.  If  there  is  a  syphilitic  element  in  the  condition  appropriate 
medical  treatment  should  be  prescribed.  If  no  result  is  obtained  operation 
with  a  view  of  making  an  anastomosis  between  the  gall-bladder  and  the 
intestine,  if  the  obstruction  is  in  the  common  duct,  should  be  undertaken. 

PARASITES  OF  THE  GALL  DUCTS. 

.As  previously  stated  round  worms  may  find  their  way  into  the  bile  passages 
and  cause  obstructive  jaundice.  The  diagnosis  of  the  condition  can  be  made 
only  by  finding  worms  or  their  ova  in  the  stools.  Infectious  micro-organisms 
may  be  carried  with  the  worms  into  the  ducts  and  cause  suppurative  inflam- 
mation with  its  attendant  symptoms. 

The  treatment  of  the  condition  is  that  of  ascariasis  (see  the  section  upon 
parasites),  unless  suppuration  has  supervened,  when  the  indications  should 
be  met  as  in  similar  infective  processes  from  other  causes. 

Hydatid  cysts,  due  to  lodgment  of  the  echinococcus  in  the  ducts,  may  develop 
and  cause  obstruction,  or  the  tumors  in  the  substance  of  the  liver  may  press 
upon  the  passages  from  without  with  similar  result. 

Other  parasites  which  have  found  harbor  in  the  gall  ducts  of  man  are  the 
distoma  hepaiicum,  the  coccidium  oviforme,  the  pentastoma  constrictmn  and  the 
halantidium  coli.  The  diagnosis  is  well-nigh  impossible  although  the  ova 
of  the  distoma  have  been  demonstrated  in  the  faeces;  the  symptoms  are  those 
of  bile  duct  obstruction  due  to  more  usual  causes. 

The  treatment  is  also  baffling,  save  in  the  obstruction  due  to  the  distoma, 
when  anthelmintics  are  indicated.  Surgical  treatment  becomes  necessary  if 
symptoms  of  suppuration  supervene. 

DISEASES  OF  THE  PANCREAS 
ACUTE  PANCREATITIS. 

Definition.  An  acute  inflammation  of  the  tissues  of  the  pancreas  occur- 
ring in  three  types,  (a)  haemorrhagic;  (b)  suppurative;  (c)  gangrenous,  which, 
although  they  often  possess  an  intimate  relation  to  one  another,  will  be  con- 
sidered separately. 


484         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

ACUTE  HEMORRHAGIC  PANCREATITIS. 

Etiology.  This,  like  other  inflammations  of  the  pancreas,  is  a  rare  afifec- 
tion.  It  is  observed  most  frequently  in  adult  males;  alcohol  seems  to  be  a 
factor  in  its  incidence;  it  also  occurs  in  patients  who  have  suffered  from  severe 
gastric  symptoms  and  gall-stone  disease.  Parturition  is  mentioned  as  a  cause, 
the  pancreas  being  either  affected  in  a  way  similar  to  that  met  in  the  kidneys 
and  liver  in  the  toxaemias  of  pregnancy  or  by  embolism  of  giant  cells  from  the 
placenta.     Traumatism  has  been  held  responsible  in  some  instances. 

Pathology.  The  pancreas  is  the  seat  of  a  general  enlargement  and  is 
infiltrated  with  blood  which  is  sometimes  present  in  clots.  Gall-stones  may 
be  found  in  the  bile  ducts.  The  cells  of  the  organ  may  have  undergone  a 
coagulation  necrosis  and  at  the  borders  of  these  necrotic  areas  the  products  of 
exudative  inflammation,  fibrin,  red  and  white  blood  cells,  are  found.  Foci 
of  fat  necrosis,  white  in  color,  may  be  observed  in  the  lobules  of  the  pancreas 
and  in  the  omentum  and  mesentery.     Bacteria  may  be  present. 

Symptoms.  The  onset  is  characteristically  sudden  with  severe  abdominal 
colic;  this  may  be  localized  in  the  upper  abdomen  or  general;  there  are  nausea 
and  vomiting  and  symptoms  of  collapse  depending  in  type  upon  the  severity 
of  the  attack.  The  pain  and  collapse  are  attributed  to  a  stretching  of  the 
cceliac  plexus  due  to  the  suddenly  appearing  sweUing.  The  abdomen  becomes 
swollen,  tympanitic,  and  tender,  and  palpation  of  the  epigastrium  may  reveal 
a  sense  of  resistance.  At  the  invasion  a  chill  may  occur  to  be  followed  by 
moderate  fever. 

The  diagnosis  is  not  easy.  Intestinal  obstruction  may  be  very  difficult 
of  differentiation,  but  sudden  severe  pain  in  the  upper  abdomen,  accompanied 
by  tenderness  and  later  a  sense  of  resistance,  with  vomiting,  collapse  and 
slight  fever,  is  suggestive  of  pancreatic  lesion.  According  to  Fitz,  scattered 
areas  of  abdominal  tenderness  and  tenderness  over  the  pancreatic  region 
are  valuable  signs. 

The  prognosis  is  distinctly  unfavorable  although  recovery  has  been 
observed  in  rare  instances.  Death  usually  takes  place  in  from  three  to 
seven  days  or,  if  life  is  prolonged,  gangrenous  pancreatitis  may  foUow. 

Treatment  consists  in  the  employment  of  means  to  lessen  the  pain,  such  as 
hot  applications  to  the  abdomen  and  the  hypodermatic  administration  of 
morphine.  The  symptoms  of  collapse  should  be  combated  by  means  of 
entero-  or  hypodermatoclyses  of  hot  normal  saline  solution  and  hypodermatic 
stimulation. 

ACUTE  SUPPURATIVE  PANCREATITIS. 

Synonym.     Pancreatic  Abscess. 

Etiology.  The  causation  of  this  condition  is  indefinite;  traumatism  and 
digestive  distiirbances  due  to  dietetic  errors  have  been  considered  as  aetiolog- 


ACUTE    GANGRENOUS    PANCREATITIS.  485 

ical  factors.  The  infection  reaches  the  organ  through  its  ducts  or  by  exten- 
sion from  some  adjacent  suppurative  focus.  Pancreatic  suppuration  may 
also  result  from  purulent  cholangitis  which  has  spread  to  the  organ  through 
its  duct. 

Pathology.  The  pancreas  is  enlarged  and  contains  one  large  abscess 
or  a  number  of  smaller  ones;  in  other  instances  a  diffuse  purulent  infiltration 
has  been  observed.  Extension  of  the  inflammation  into  the  tissues  surround- 
ing the  pancreas  may  occur  or  rupture  into  neighboring  structures,  peri- 
tonaeum, stomach,  etc.,  may  take  place.  Thrombosis  of  the  portal  and  splenic 
veins  has  been  described.     Fat  necrosis  is  unusual. 

Symptoms.  In  acute  instances  the  onset  is  sudden  with  epigastric  pain, 
vomiting  and  a  pyaemic  temperature  with  rigors  and  sweats.  The  abdomen 
is  tense  and  tympanitic  and  the  spleen  may  be  enlarged.  There  may  be 
fatty  diarrhoea,  glycosuria  and  jaundice.  The  patient  is  markedly  pros- 
trated and  death  often  takes  place  within  a  week.  At  other  times  the  course 
is  more  prolonged,  emaciation  is  marked  and  progressive,  and  rupture  of  the 
pus-containing  cavity,  with  accompanying  symptoms  may  occur. 

The  diagnosis  is  very  difficult ;  the  existence  of  a  tender  mass  in  the  epigas- 
trium with  fatty  diarrhoea  and  sugar  in  the  lurine  should  be  of  great  aid  in  differ- 
entiation. 

The  prognosis  is  unfavorable  but  recovery  after  operation  has  been  ob- 
served. 

Treatment,  aside  from  symptomatic  and  supportive  measures  is  essenti- 
ally surgical. 

ACUTE  GANGRENOUS  PANCREATITIS. 

Etiology.  This  affection  is  usually  a  sequela  of  pancreatic  haemorrhage. 
It  may  follow  perforative  ulcer  of  the  stomach,  intestine  or  biliary  tract  or 
even  extension  through  the  pancreatic  duct  of  a  cholangitis.  Traumatism 
is  also  an  aetiological  factor. 

Pathology.  The  pancreas  is  usually  changed  into  a  dark  slate-colored 
mass,  soft  and  putrid,  and  is  surrounded  by  a  thin  greenish  or  dark-colored 
purulent  fluid;  it  may  lie  nearly  free  in  the  cavity  of  the  omentum  or  in  an 
abscess  cavity  which  is  plainly  palpable  externally.  In  other  instances  the 
organ  is  dry  and  necrotic.     Scattered  areas  of  fat  necrosis  are  frequent. 

Symptoms.  These  are  usually  those  of  acute  haemorrhagic  pancreatitis 
followed  after  a  few  days  by  fever,  chills,  abdominal  distention  with  tenderness 
and  jaundice.  Death  in  collapse  takes  place  in  a  few  days  to  two  or  three 
weeks.  Recovery  has  followed  the  discharge  through  the  rectum  of  the 
necrotic  organ. 

Treatment  is  symptomatic  and  supportive.  Operation,  if  indicated,  may 
be  undertaken. 


486         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

CHRONIC  PANCREATITIS. 

Etiology.  Chronic  inflammation  of  the  pancreas  may  follow  acute  pan- 
creatitis or  catarrhal  inflammation  of  the  duct  of  Wirsung  which  has  resulted 
from  a  chronic  gastro-duodenitis.  Gall-stone  disease  is,  however,  respon- 
sible for  a  large  proportion  of  instances  and  consequently  the  causation  of 
these  is  that  of  the  primary  cholehthiasis  (see  the  section  upon  this  subject). 
Chronic  pancreatitis  may  also  arise  by  extension  of  neighboring  inflamma- 
tions.    Syphilis  may  be  mentioned  as  a  cause. 

Pathology.  The  organ  may  be  increased  in  size.  Two  types  of  chronic 
pancreatic  inflammation  are  described  the  interlobular  and  the  inter  acinar . 
The  former  is  less  diffuse  than  the  latter  and  does  not  interfere  by  its  new 
growth  of  connective  tissue  with  the  functions  of  the  islands  of  Langerhans. 
Inter-acinar  inflammation  invades  these  structures  and  may  result  in  their 
obliteration.  The  changes  in  the  two  forms  of  the  affection  are  comparable 
to  those  occurring  in  the  liver  in  hypertrophic  and  atrophic  cirrhosis,  the 
distinctive  feature  being  an  increased  production  of  connective  tissue  which 
may  be  more  or  less  localized  in  one  part  of  the  organ. 

Symptoms.     These  are   not   characteristic. 

The  patient  may  suffer  for  years  from  digestive  disorders  with  intermittent 
diarrhoea.  Later  jaundice  and  ascites  may  occur  with  paroxysmal  pain 
felt  deep  in  the  epigastric  region.  Faintness  and  gradual  emaciation  may 
be  present.  The  presence  of  glucose  and  fat  may  be  demonstrated  in  the 
urine  and  fat  may  appear  in  the  stools.  If  there  is  organic  change  in  the 
pancreas,  which  permanently  interferes  with  the  functions  of  the  islands  of 
Langerhans,  the  glycosuria  is  likely  to  be  permanent  (diabetes  mellitus). 
Should  there  be  only  temporary  glycosuria  the  probability  is  that  the  affection 
of  the  islands  is  merely  functional. 

Upon  palpation  a  circumscribed  resistance  over  the  pancreatic  region  may 
be  detected  and  in  rare  instances  the  organ  itself  or  its  head  may  be  distinctly 
palpable. 

The  prognosis  as  to  cure  is  unfavorable  but  there  may  be  advanced  disease 
of  the  organ  without  great  interference  with  general  health. 

Treatment.  The  similarity  in  the  causation  between  this  and  gall-stone 
disease  is  marked,  consequently  we  could  hardly  do  better  than  to  prescribe 
an  analogous  method  of  treatment.  The  dietetic  and  hygienic  methods 
suggested  for  cholelithiasis  are  applicable  here  and  the  administration  of 
such  a  pill  as  that  mentioned  on  p.  480  and  composed  of  i^  grains  (o.i) 
each  of  acid  sodium  oleate  and  salicylic  acid,  i  grain  (0.065)  of  phenolphtha- 
lein  and  \  grain  (0.016)  of  menthol,  in  the  same  fashion  as  there  described,  is 
recommended. 

It  has  been  suggested  that,  since  fats  and  sugars  need  the  pancreatic  secre- 


CANCER  OF  THE  PANCREAS.  487 

tion  for  their  digestion,  foods  of  these  classes  be  restricted,  or  if  allowed,  that 
pancreatin  in  doses  of  from  5  to  10  grains  (0.33  to  0.66)  be  given.  Diastase 
and  pancreatic  substance  chopped  fine  may  also  be  given  as  an  aid  to  their 
digestion. 

Accompanying  biliary  obstruction  due  to  stone  or  other  causes  may  necessi- 
tate appropriate  surgical  measures. 

TUMORS  OF  THE  PANCREAS. 

Pancreatic  tumors  occur  as  cancer  (carcinoma,  more  rarely  adenoma, 
sarcoma  or  lymphoma),  as  non-malignant  cystic  growths,  or  as  syphilitic 
gummata. 

Cancer  of  the  Pancreas. 

As  previously  stated  the  most  common  malignant  growth  affecting  the 
pancreas  is  the  carcinoma;  it  may  be  of  either  scirrhous  or  colloid  type.  Pri- 
mary tumors  are  usually  situated  in  the  head  of  the  gland  but  the  involvement 
may  be  confined  to  any  part  of  the  organ.  Secondary  carcinoma  may  spread 
to  the  pancreas  from  similar  growths  in  contiguous  structures.  Like  other 
malignant  tumors,  cancer  of  the  pancreas  is  usually  observed  in  individuals 
beyond  middle  age. 

Symptoms.  The  condition  is  difi&cult  of  recognition;  of  the  usual 
symptoms  the  following  are  most  important.  Paroxysmal  pain  in  the 
epigastrium  with  gastric  irritability;  jaundice  (when  the  growth  is  in 
the  head  of  the  organ)  due  to  pressure  upon  and  obstruction  of  the 
common  bile  duct;  this  icterus  may  be  extreme  and  associated  with  bile- 
stained  iirine,  light  colored  stools,  dilatation  of  the  gall-bladder,  fatty  stools 
and  glycosuria  which  last,  however,  are  by  no  means  constant;  emaciation 
with  steadily  increasing  cachexia;  the  presence  of  an  immovable  tumor  in 
the  epigastrium,  which  may  not  be  palpable  unless  the  patient  is  subjected 
to  anaesthesia.  In  thin  patients  the  pulsation  of  the  aorta  transmitted  through 
the  overlying  tumor  may  be  appreciated. 

The  diagnosis.  The  distinctive  features  of  the  affection  are  the  jaundice 
and  the  presence  of  an  immovable  tumor  with  rapid  emaciation.  Cancer 
of  the  pylorus  is  not  associated  vdth  icterus,  except  in  rare  instances,  and  is 
usually  movable,  the  results  of  gastric  analysis  are  characteristic  and  there 
is  consequent  dilatation  of  the  stomach.  Carcinoma  of  the  colon  may  be 
movable  and  there  is  no  icterus  in  this  condition;  intestinal  obstruction  occurs 
in  the  late  stages. 

The  prognosis  is  unfavorable  unless  the  diseased  portion  of  the  gland  can 
be  removed. 


488         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITON.EUM. 

Treatment  from  a  medical  standpoint  is  symptomatic  and  supportive 
only.  Surgical  removal  of  the  disease  has  resulted  in  cure  in  a  number  of 
instances. 

Cysts  of  the  Pancreas. 

.Etiology.  Retention  cysts  of  the  pancreas  result  from  occlusion  of  the 
ducts  of  the  organ  due  to  compression.  The  pressure  may  be  exerted  by 
influences  virithin  or  without  the  substance  of  the  gland.  Traumatism  or 
prolonged  pressure  is  responsible  in  certain  instances.  Obstruction  occurs 
as  a  result  of  the  impaction  of  gall-stones  or  pancreatic  calculi,  of  the  contrac- 
tion of  newly  produced  connective  tissue  (sclerosis),  of  inflammations  of  the 
lining  of  the  pancreatic  ducts  occurring  as  a  result  of  the  extension  of  catarrhal 
processes  in  the  duodenal  mucous  membrane  and  of  displacements  of  the 
organ  causing  a  kink  in  its  duct. 

.  Adults  are  more  frequently  affected  with  cystic  conditions  of  the  pancreas 
but  the  afi'ection  has  been  observed  in  children. 

Pathology.  The  cysts  vary  much  in  size  and  may  be  single  or  multiple; 
single  cysts  containing  several  gallons  of  fluid  have  been  found.  In  the 
early  stages  the  contents  is  normal  pancreatic  juice,  later  it  becomes  dark  in 
color  and  may  contain  albumin  and  blood.  The  reaction  is  alkaline  and  the 
specific  gravity  from  1,010  to  1,025.  The  characteristic  pancreatic  ferment 
may  be  present.  Under  the  microscope,  in  addition  to  red  and  white  blood 
cells,  oil  droplets  and  degenerated  epithelial  cells,  fatty  acid  and  cholesterin 
crystals  may  be  found. 

Symptoms.  There  may  be  colicky  abdominal  pain  with  nausea  and 
vomiting  or  these  symptoms  may  be  wholly  absent;  the  patient  may  perceive 
nothing  unusual  until  the  increasing  size  of  the  abdomen  comes  before  his 
notice.  Jaundice  and  ascites,  due  to  pressure  upon  the  bile  ducts  and  portal 
vessels,  may  be  present  with  large  cysts.  Fatty  diarrhoea  and  pancreatic 
salivation  are  rare;  glycosuria  may  be  present.  Disappearance  of  the  cyst 
and  its  symptoms  may  take  place  suddenly,  due  to  temporary  relief  of  the 
obstruction. 

The  diagnosis  depends  upon  the  result  of  physical  examination.  In 
typical  instances  the  tumor  lies  in  the  mid-line  of  the  upper  abdomen;  in 
those  of  extreme  type  the  cyst  may  fill  almost  the  entire  abdominal  cavity. 
It  is  seldom  mobile  and  does  not  descend  with  inspiration;  its  surface  is 
smooth  or  lobulated  and  it  is  elastic  in  consistency.  The  stomach  may  be 
demonstrated  above  and  the  colon  below  the  tumor.  Percussion  reveals  the 
presence  of  a  flatness  which  is  not  continuous  with  the  dull  note  elicited  over 
the  liver  or  spleen.  Fluid  aspirated  from  the  cyst  should  digest  albumin 
and  emulsify  fat,  but  the  former  characteristic  only,  is  pathognomonic,  for 
numerous  exudates  and  transudates  contain  fat-emulsifying  ferments. 


ACUTE    PERITONITIS.  489 

The  prognosis  under  proper  treatment  is  good. 

Treatment  is  exclusively  surgical  and  consists  of  incision  and  drainage. 
Extirpation  of  the  cyst  has  been  followed  by  diabetes  mellitus. 

PANCREATIC  CALCULI. 

Etiology.  Pancreatic  lithiasis  is  a  rare  condition.  The  stone  is  probably 
the  result  of  inflammation  of  the  pancreatic  duct  with  resulting  abnormality 
in  the  composition  of  the  secretion  and  ultimate  precipitation. 

Pathology.  The  calculi  are  whitish  in  color  and  often  multiple;  in  size 
they  vary  from  that  of  a  grain  of  sand  to  that  of  a  good  sized  pea.  They 
may  be  rounded  and  smooth  or  irregular  and  rough.  They  are  composed 
chiefly  of  calcium  carbonate,  sometimes  with  the  addition  of  calcium  phosphate. 
The  irritation  caused  by  their  presence  may  result  in  inflammation  of  the 
pancreas,  with  dilatations  of  the  duct  or  even  of  the  gland  itself,  suppurative 
inflammation  of  the  organ  or  even  cancer. 

Symptoms.  The  colic  due  to  passage  of  the  stone  into  the  duodenum  is  very 
like  that  due  to  gall-stones  and  it  is  practically  impossible  to  differentiate  the 
two  conditions,  particularly  since  jaundice  may  be  a  feature  of  both.  Glyco- 
suria and  fatty  diarrhoea  with  colic  in  the  upper  abdomen  may  give  the  clue 
to  the  diagnosis  of  pancreatic  stone.  If  calculi  composed  of  calcium  carbonate 
are  found  in  the  fasces  the  diagnosis  is  assured. 

The  prognosis  depends  upon  the  development  of  sequelae  such  as  chronic 
pancreatitis,  suppuration  or  cancer. 

Treatment.  The  attacks  of  colic  should  be  controlled  by  the  means  sug- 
gested for  the  relief  of  biliary  colic  (q.v.).  Disturbances  of  digestion  should 
receive  appropriate  treatment  and  one  instance  has  been  reported  where  the 
administration  of  8  to  15  minims  (0.5  to  i.o)  of  a  i  percent,  solution  of  pilo- 
carpine three  times  a  week,  with  the  object  of  increasing  the  pancreatic  secretion, 
was  successful  in  checking  the  attacks.  Hydrochloric  acid  is  also  said  to 
promote  the  flow  of  pancreatic  juice  and  its  employment  is  worthy  of  trial. 

DISEASES  OF  THE  PERITONiEUM. 
ACUTE  PERITONITIS. 

Definition.     An  acute   inflammation   of  the  peritonaeum. 

^Etiology.  Primary  acute  inflammation  of  the  peritonseal  membrane  is  a 
very  rare  affection  but  is  said  to  occur  as  a  result  of  exposure  to  cold  and 
wet  and  has  been  termed  rheumatic  or  idiopathic  peritonitis. 

Secondary  peritonitis  is  frequent  and  is  due  to  the  extension  of  an  inflam- 
mation of  any  of  the  structures  adjacent  to  the  peritonasal  membrane,  to  rupture 


49°        DISEASES    OF   THE   DIGESTIVE    SYSTEM   AND    PERITONEUM. 

of  any  of  the  viscera  which  the  membrane  surrounds  or  to  abdominal  opera- 
tions which  have  been  performed  without  due  regard  to  perfect  asepsis. 

Of  peritonitis  caused  by  extension,  inflammations  or  tumors  of  any  of  the 
following  organs  or  structures  may  be  at  fault;  the  stomach,  the  intestines, 
the  liver,  the  gall-bladder,  the  spleen,  the  pancreas,  the  organs  of  either  the 
male  or  female  genito-urinary  system.  Abscess  of  the  peri-renal  tissue,  of 
the  spine,  as  in  Pott's  disease,  or  the  cold  psoas  abscess  may  cause  peritonitis 
by  rupture  or  by  extension. 

Peritonitis  also  may  follow  rupture  of  any  of  the  viscera  named  above  but 
the  most  important  causes  of  perforative  peritonitis  are  appendicitis  and 
rupture  of  suppurative  processes  involving  the  structures  about  the  ovaries 
and  Fallopian  tubes.  In  considering  the  aetiology  of  peritonitis,  perforation 
of  the  viscera  resulting  from  external  wounds  must  not  be  forgotten. 

Peritonitis  also  occurs  as  a  complication  of  acute  polyarthritis  and  pleuritic 
inflammations  and  sometimes  as  a  terminal  infection  in  chronic  nephritis, 
arteriosclerosis  and  gouty  conditions 

Secondary  peritonitis  is  without  exception  of  microbic  origin  and  the  causa- 
tive bacteria  are  either  those  responsible  for  the  primary  inflammation  or  those 
introduced  into  the  peritonseal  cavity  with  the  contents  of  the  ruptured  viscus; 
the  most  usually  found  organisms  are  staphylococci  pyogenes  aurei  or  alhi, 
streptococci  and  bacilli  coli  communes.  Less  commonly  found  are  the  tubercle 
bacillus,  the  bacillus  of  enteric  fever,  the  pneumococcus,  the  bacillus  of  epi- 
demic influenza,  the  bacillus  pyocyaneus,  the  bacillus  aerogenes  capsulatus, 
the  bacillus  proteus  and  the  gonococcus.  The  amoeba  coli  has  been  found 
in  peritonitis  occurring  with  tropical  dysentery.  In  some  instances  the 
infection  may  be  due  to  a  single  t}-pe  of  micro-organism  but  much  more  fre- 
quently cultures  from  the  inflammatory  exudate  will  show  a  mixed  infection. 
The  mono-infections  occur  more  especially  in  peritonitis  secondary  to  or 
accompanying  nephritis  as  a  terminal  infection,  acute  rheumatism,  gout, 
arteriosclerosis  and  pleurisy. 

Pathology.  The  intestines  are  distended  with  gas  and  their  peritonseal 
surface  is  congested;  the  coils  of  gut  are  more  or  less  adherent  to  one  another 
due  to  an  exudation  of  lymph-like  substance  which  is  made  up  of  fibrin  and 
white  blood  cells.  The  inflammatory  exudate  upon  the  surface  of  the  peri- 
tonaeum or  into  its  cavity  may  be  of  fibrin  only,  of  serum  with  fibrin,  of  pus, 
creamy  or  greenish  in  color,  or  of  bloody  serum,  especially  in  instances  due  to 
external  wound.  In  early  stages,  before  the  appearance  of  fluid,  the  peri- 
tonaeum is  slightly  roughened  and  its  lustre  is  dulled.  Foul  fluid  mixed  with 
intestinal  contents  is  present  in  peritonitis  due  to  perforation  of  the  intestine, 
and  after  rupture  of  the  uterus  occurring  in  puerperal  or  carcinomatous  con- 
ditions, a  foetid,  grayish-green  exudation  is  often  observed.  The  amount 
of  fluid  present  varies  from  a  small  quantity  to  20  quarts  (litres)  or  more. 


ACUTE    PERITONITIS.  49 1 

In  instances  of  long  standing  the  lymph  adhesions  between  the  coils  of 
intestine  and  other  viscera  become  organized  and  may  finally  result  in  the 
formation  of  dense  bands  of  tissue.  In  circumscribed  peritonitis  these  are 
especially  noticeable  and  the  adhesions  may  wall  off  localized  collections  of 
pus  or  abscesses  which  may  rupture,  which  event  is  followed  by  a  general 
peritonseal  inflammation. 

Symptoms.  Acute  generalized  peritonitis  when  due  to  perforation  is  sudden 
in  its  onset  and  characterized,  in  very  acute  instances,  by  a  fall  of  temperature 
and  evidences  of  collapse,  such  as  great  prostration,  cold  perspiration  and 
rapid,  small  and  weak  pulse;  there  is  abdominal  pain  with  general  tenderness. 
The  respirations  are  shallow,  rapid  and  thoracic  rather  than  abdominal. 
After  the  chill  of  the  invasion  there  may  be  moderate  fever,  rarely  is  the  tem- 
perature high,  and  it  may  remain  normal  or  even  below  this  point.  The 
urine  is  scanty  and  may  contain  indican.  The  pain  is  often  severe  and  is 
greatly  increased  by  motion  but  at  times  the  patient,  if  he  is -allowed  to  lie 
quietly  in  the  position  which  he  chooses — usually  with  the  thighs  flexed  and 
the  shoulders  raised  so  as  to  relax  the  abdominal  muscles — makes  little  com- 
plaint. The  abdominal  wall  is  tense  and  hard  and  upon  examination  tend- 
erness and  a  tympanitic  percussion  note  are  observed.  The  tongue  is  moist 
at  first;  later  it  becomes  dry  and  cracked.  Vomiting  is  early,  frequent  and 
very  painful;  the  vomitus  consists  of  stomach  contents,  followed  by  thin  bile- 
stained  fluid  and  ultimately  by  dark  liquid,  sometimes  of  faecal  odor.  The 
bowels  are  often  loose  at  first  but  constipation  soon  supervenes. 

Physical  examination,  in  addition^to  the  signs  already  mentioned,  reveals 
a  typical  facies — the  Hippocratic  countenance — the  eyes,  cheeks  and  temples 
being  sunken,  the  nose  pinched,  the  lobes  of  the  ears  turned  out,  the  forehead 
rough  and  dry  and  the  skin  dark  or  livid.  The  abdomen  is  tympanitic, 
the  diaphragm  and  the  cardiac  apex  may,  be  displaced  upward  and  both 
liver  (Clark's  sign)  and  splenic  dulness  may  be  obscured  or  even  obliterated. 
These  manifestations  are  particularly  marked  if  air,  as  well  as  fluid,  is  present 
in  the  peritonaeum;  this  takes  place  when  the  perforation  involves  an  air-con- 
taining viscus.  If  the  patient  lives  long  enough,  fluid,  with  its  characteristic 
signs,  appears  in  the  peritoneeum.  It  is  evidenced  by  increasing  dulness  in 
the  flanks,  the  extent  of  which  is  altered  by  a  change  in  the  position  of  the 
patient.  There  may,  however,  be  a  considerable  effusion  without  movable 
dulness;  a  peritonasal  friction  sound  may  be  detected.  In  determining  the 
presence  of  pneumoperitonitis  one  must  remember  that  in  this  condition 
hepatic  dulness,  even  in  the  mid-axillary  line  when  the  patient  is  on  his  left 
side,  may  be  absent,  while  when  fluid  alone  is  present  liver  dulness  exists  under 
these  circumstances  although  it  may  be  absent  when  he  lies  flat  on  his  back. 

The  mental  condition  usually  remains  clear  until  near  the  termination  of 
the  disease  when  coma  or  delirium  may  supervene.     As  the  end  approaches 


492         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONAEUM. 

the  pulse  becomes  feebler  and  feebler,  irregular  and  intermittent,  the  tem- 
perature rises,  although  the  skin  may  remain  cold,  and  death  occurs.  In  the 
fulminating  type  of  peritonitis  this  event  may  take  place  within  two  days,  in 
less  severe  infections  the  course  may  be  prolonged  for  a  week  or  more.  At 
times  sudden  death  occurs,  due  probably  to  cardiac  paralysis. 

Acute  localized  peritonitis  is  characterized  by  symptoms  analogous  to  those 
of  general  peritonitis  but  they  are  much  less  severe  and  are  usually  associated 
with  those  of  the  primary  disease  to  which  the  peritonaeal  inflammation  is 
due.  The  onset  of  the  symptoms  is  slower,  those  of  the  peritonitis  being 
gradually  engrafted  upon  those  of  the  causative  lesion.  The  pain  is  less 
marked  and  more  distinctly  localized,  and  the  same  is  true  of  the  tenderness; 
vomiting  may  also  be  present.  There  is  progressive  weakness  but  the  course 
of  the  affection  is  longer,  the  temperature  is  more  generally  elevated  and  is 
likely  to  be  of  septic  type.  The  evolution  of  the  disease  is  less  rapid  and 
recovery  is  much  more  frequent  than  in  general  infection  of  the  peritonaeum. 

The  most  frequent  situations  of  localized  peritonitis  are  in  the  neighborhood 
of  the  appendix,  as  a  result  of  inflammations  of  this  structure,  and  in  the 
pelvis  where  infective  conditions  of  the  female  generative  organs  are  respon- 
sible. Subdiaphragmatic  abscesses  involving  the  peritonaeum  between  the 
upper  abdominal  viscera  and  the  diaphragm  are  a  not  unusual  form  of  cir- 
cumscribed peritonaeal  inflammation. 

The  diagnosis  of  general  peritonitis  with  the  typical  sudden  onset,  tender- 
ness, distention,  collapse,  etc.,  is  not  difficult  especially  if  there  is  a  history 
of  possibly  causative  lesion  such  as  that  of  repeated*  attacks  of  appendiceal 
pain  or  of  ovarian  or  tubal  disorders.  In  enteric  fever  the  diagnosis  of  per- 
forative peritonitis  may  be  obscured  by  the  fact  that  abdominal  tenderness 
and  distention  are  not  unusual  symptoms  of  the  uncomplicated  disease,  but 
the  sudden  appearance  of  pain,  tenderness,  abdominal  rigidity,  fall  in  tem- 
perature and  collapse  in  a  conscious  patient  is  a  very  reliable  index  of  this 
serious  complication. 

The  most  important  conditions  to  be  differentiated  from  general  peritonitis 
are: 

1.  Hysterical  peritonitis.  This  is  observed  in  women  and  is  a  most  baf- 
fling condition.  It  simulates  every  detail  of  true  peritonitis  almost  exactly, 
even  to  the  collapse  and  temperature.  The  patient,  however,  does  not  die 
and  the  accompanying  hysterical  manifestations  are  likely  to  give  the  clue 
to  the  diagnosis. 

2.  Intestinal  obstruction  is  also  difiicult  of  separation,  but  the  history 
of  the  patient  usually  affords  help. 

3.  Ruptured  ectopic  pregnancy  is  accompanied  by  many  of  the  symp- 
toms of  peritonitis,  but  here  also,  the  history  aids  in  differentiation. 

4.  Rupture  of  abdominal  aneurysm,  embolism  of  the  mesenteric  vessels, 


ACUTE    PERITONITIS.  493 

acute  entero-colitis  and  hemorrhagic  pancreatitis  are  other  possibilities  which 
must  be  excluded  in  the  differential  diagnosis  of  acute  peritonitis. 

The  diagnosis  of  localized  peritonitis  is  greatly  facilitated  by  the  history 
of  a  causative  lesion.  If  the  collection  of  pus  is  near  the  skin  it  may  be  possible 
to  detect  the  presence  of  fluctuation  and  in  some  instances  the  aspirator  may 
be  employed  to  advantage. 

The  prognosis  of  general  peritonitis  is  distinctly  unfavorable  unless  imme- 
diate operative  interference  is  undertaken;  the  earlier  the  peritonasal  cavity 
is  opened  and  drained  the  better  are  the  chances  of  recovery,  a  fact  which 
should  emphasize  the  importance  of  early  diagnosis.  The  same  is  true  of 
localized  acute  peritonitis  although  spontaneous  cure  following  external 
rupture  has  been  observed. 

Treatment.  Much  can  be  done  in  the  way  of  preventing  puerperal  and 
post-operative  peritonitis  by  proper  attention  to  asepsis  and  antisepsis  in 
surgery  and  midwifery. 

When  there  is  any  possibility  of  the  occurrence  of  perforative  peritonitis, 
or  this  or  any  other  type  of  the  infection  has  occurred,  the  patient  should  be 
kept  absolutely  at  rest ;  if  the  patient  is  unwilling  to  lie  quietly  the  importance 
of  implicit  obedience  to  the  physician's  orders  should  be  explained  and  if  he 
is  still  obstreperous  he  should  be  restrained;  usually,  however,  the  sufferer 
from  peritonitis  is  quite  willing  to  lie  still  on  account  of  the  increased  pain 
which  movement  induces.  Passive  movements  for  purposes  of  physical 
examination  are  justifiable  but  should  be  as  limited  as  possible.  It  has  been 
suggested  that  the  best  position  in  which  the  patient  can  lie  is  one  in  which 
the  lumbar  portion  of  the  abdominal  cavity  is  lowest  in  order  that  the  infectious 
exudate  may  be  prevented  from  reaching  the  pelvic  peritonaeum  and  that  of  the 
subphrenic  region.  This  object  may  be  accompHshed  by  raising  the  foot 
of  the  bed  and  by  propping  the  patient's  shoulders  by  means  of  pillows. 

The  prevention  of  possible  perforative  peritonitis  by  means  of  excision  of 
gastric  ulcers  is  a  surgical  measure  that  has  received  much  attention  of  late. 

Peristalsis  should  be  prevented,  for  by  this  action  of  the  intestinal  muscu- 
lature the  dissemination  of  infectious  matter  through  the  peritonaeal  cavity 
is  favored  and  the  formation  of  adhesions  which  may  wall  off  the  inflamma- 
tion may  be  interfered  with;  consequently  all  influences  which  cause  peris- 
talsis should  be  avoided  and  it  has  been  advised  to  allow  nothing  by  mouth, 
not  even  water  for  two  or  three  days  after  the  onset  of  the  peritonitis.  Thirst 
may  be  relieved  by  permitting  the  patient  to  dissolve  bits  of  ice  in  the  mouth, 
but  the  resulting  water  must  not  be  swallowed;  stimulation  may  be  given  and 
water  provided  to  the  tissues  by  frequent  small  enemata  of  saline  solution 
provided  this  measure  does  not  increase  the  patient's  discomfort  too  much. 

Hypodermatoclysis  of  salt  solution — a  quart  (litre)  or  more  given  twice 
a  day — is  an  excellent  and  effective  measure.     When  the  necessity  for  food 


494         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

has  become  urgent,  this  must  be  given  by  the  rectum;  hypodermatic  injections 
of  oil  are  also  useful  in  this  connection. 

The  pain  may  be  relieved  by  the  application  of  the  ice  coil,  hot  compresses 
or  turpentine  stupes  made  with  ice  water.  Local  applications  should  always 
be  of  as  light  weight  as  possible  for  obvious  reasons. 

Opium  and  morphine  do  not  influence  the  disease  itself  to  the  least  degree 
but  are  useful  in  the  control  of  the  pain,  restlessness  and  vomiting.  These 
drugs,  especially  the  latter,  also  lessen  peristaltic  action  and  are  of  additional 
benefit  for  this  reason.  Morphine  administered  hypodermatically  is  usually 
preferable  to  opium  by  mouth  or  rectum.  The  abdominal  distention  is  an 
obstinate  symptom  but  may  yield  to  the  usual  symptomatic  measures;  the 
introduction  of  the  rectal  tube  and  high  enemata  are,  however,  not  advisable. 
Hiccough,  which  is  not  infrequently  a  distressing  symptom,  may  be  relieved  by 
atropine  or  morphine  given  under  the  skin. 

Heart  weakness  and  tendency  to  collapse  necessitate  free  hypodermatic 
stimulation  by  means  of  strychnine,  alcohol,  aether  and  other  quickly  acting 
drugs;  digitalis  is  especially  indicated  in  the  slow,  weak  pulse  of  low  tension, 
but  its  action  is  too  slow  for  use  in  a  condition  where  immediate  results  are 
desired.  Hypodermatoclysis  of  hot  normal  saline  solution  is  an  excellent 
means  of  combating  collapse  and  the  hypodermatic  use  of  adrenalin  in  doses 
of  20  to  30  minims  (1.33  to  2.0)  of  the  i  to  1,000  solution  has  been  recommended. 
Hot  baths  at  104°  F.  (40°  C.)  are  said  to  be  an  efficient  method  of  tiding  over 
an  attack  of  collapse. 

Medical  treatment  in  general  peritonitis  is  at  best  unsatisfactory  and  ineffec- 
tual, except  in  so  far  as  by  its  employment  we  are  enabled  to  relieve  the  distress 
of  a  dying  patient.  The  only  truly  curative  treatment  of  this  disease  is  imme- 
diate opening  of  the  abdominal,  cavity  and  the  establishment  of  proper  drain- 
age. The  conditions  found  upon  operation  necessitate  the  adaptation  of 
the  details  of  the  procedure  to  the  case  in  hand.  It  is  generally  conceded 
that  radical  surgical  measures  should  be  undertaken  as  soon  as  the  diagnosis 
is  established  and  certain  conservative  surgeons  are  advocating  operation  as  a 
preventive  measure,  as  for  instance  in  the  presence  of  gastric  ulcer  with  local- 
ized peritonitis  and  imminent  rupture. 

The  treatment  of  locaHzed  exudative  processes  in  the  peritonaeum  is  also, 
in  the  main,  operative.  It  may  be  possible  to  relieve  the  symptoms  by  such 
local  applications  as  those  suggested  in  a  previous  paragraph  but  in  general 
it  may  be  safely  stated  that  the  sooner  the  patient  is  placed  in  the  hands  of  a 
skilful  surgeon  or  gynaecologist  the  better  are  the  opportunities  for  recovery. 

CHRONIC  PERITONITIS. 

This  type  of  peritonaeal  inflammation,  like  the  preceding,,  may  be  either 
local  or  general. 


CHRONIC    PERITONITIS.  495 

Local  or  circumscribed  peritonitis  of  chronic  course  may  result  from  the 
extension  of  inflammations  of  the  organs  involved  by  the  peritonaeum.  It  is 
especially  common  in  the  regions  of  the  liver,  spleen  and  diaphragm  and  is 
characterized  by  adhesions  between  these  structures;  it  is  also  frequent  in 
the  pelvis.  The  peritonaeal  adhesions  which  so  frequently  follow  intra- 
abdominal surgical  operations  must  be  considered  as  a  variety  of  this  affection. 
External  traumatism  is  likewise  an  aetiological  factor. 

Pathology.  Fibrous  adhesions  occur  between  the  coils  of  intestine,  the 
peritonaeum  and  the  diaphragm,  the  pelvic  portion  of  this  membrane  and 
the  near-by  structures.  Areas  of  thickening  or  contraction  of  the  periton- 
aeum may  be  observed. 

Symptoms.  Marked  adhesions  may  occur  which  never  give  rise  to  sus- 
picion of  their  presence.  In  other  instances  there  may  be  colicky  pain  in  the 
abdomen  due  to  a  stretching  of  the  adhesions  by  peristalsis;  constipation  is 
often  present  and  vague  abdominal  discomfort  is  common.  Contraction 
of  the  fibrous  bands  or  entanglement  of  the  intestine  in  one  of  these  may  result 
in  obstruction  of  the  bowel  with  its  attendant  symptoms.  A  peritonaeal  fre- 
mitus may  be  palpable. 

Treatment.  The  abdominal  discomfort  may  be  relieved  by  wearing  a 
properly  fitting  belt  or  binder  in  some  instances.  Internal  medication  can 
have  no  effect  upon  the  adhesions  but  inunctions  of  10  percent,  iodine  in 
vasogen  may  possibly  result  in  a  tendency  to  absorption  of  the  newly  produced 
tissue.  If  the  symptoms  are  sufficiently  severe,  radical  surgical  measures  may 
be  undertaken  with  the  object  of  breaking  up  the  adhesions,  but  the  possibility 
of  their  reformation  must  not  be  forgotten. 

Chronic  diffuse  peritonitis  may  occur  secondarily  to  mild  acute  general 
peritonitis,  in  association  with  the  venous  congestion  caused  by  chronic  disease 
of  the  heart  or  liver,  as  a  result  of  repeated  abdominal  paracentesis  for  ascitic 
conditions  or  following  external  trauma.  The  marked  proliferative  thicken- 
ings of  the  peritonaeum  which  are  sometimes  accompanied  by  similar  con- 
ditions of  the  pleura  and  pericardium  {panserositis)  are  to  be  considered  as  a 
type  of  this  variety  of  peritonitis. 

Pathology.  The  condition  of  the  peritonaeum  is  in  some  respects  similar 
to  that  obtaining  in  tuberculosis  and  cancer  of  this  membrane.  There  is 
an  extreme  degree  of  thickening  and  the  intestines  may  be  firmly  adherent 
to  themselves  or  neighboring  structures;  at  other  times  the  thickening  is  the 
most  salient  lesion,  few  or  slight  adhesions  being  present.  The  peritonaeum 
is  whitish  in  color  and  non-transparent;  the  thickening  is  frequently  much 
more  marked  in  certain  places  than  in  others  and  the  liver  and  spleen  are 
often  surrounded  by  a  firm  tough  layer  of  fibrous  tissue  which  by  its  shrinkage 
may  have  caused  considerable  decrease  in  their  size.  Thickening  and  shrink- 
age of  the  mesentery  and  omentum  are  present  and  the  portal  vein  may  be 


496         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

constricted.  A  serous  effusion  is  frequently  observed  and  adliesions  may 
separate  the  general  cavity  into  several  smaller  ones  each  of  which  may  con- 
tain fluid.     Nodules,  resembling  tuberculous  deposits,  may  be  found. 

Chronic  diffuse  peritonitis  with  a  haemorrhagic  effusion  occurs  in  cancerous 
and  tuberculous  disease  and  also  as  a  condition  ■  similar  to  haemorrhagic 
cerebral  pachymeningitis.  This  type  of  the  affection  is  usually  confined  to 
the  pelvis,  the  haemorrhage  being  due  to  rupture  of  new  vessels  formed  in  the 
peritonasal  proliferation. 

Symptoms.  These  are  analogous  to  those  of  a  very  slow  grade  of  acute 
peritonitis;  constipation  is  frequent,  oedema  of  the  extremities  and  abdominal 
wall  may  be  observed,  albuminuria  may  occur  and  there  is  sometimes  a  mild 
type  of  fever. 

Physical  examination  reveals  the  presence  of  ascites,  and  nodular  thickenings 
and  swellings  within  the  abdomen  may  be  felt. 

The  diagnosis  is  often  very  difficult;  ascites  due  to  hepatic  disease  may  be 
differentiated  by  means  of  examination  of  the  aspirated  fluid.  The  fluid  of 
peritonitis  is  higher  in  specific  gravity  (1,018),  is  less  clear  and  contains  more 
albumin. 

Treatment.  The  treatment  of  chronic  diffuse  peritonitis  is  identical  with 
that  of  the  localized  type  of  the  inflammation. 

Tapping  and  radical  surgical  measures  may  be  undertaken  if  benefit  seems 
likely  to  result. 

NEOPLASMS  OF  THE  PERITONAEUM. 

These  are  of  two  main  types,  tuberculous  (which  has  been  dealt  with  under 
the  general  subject  of  tuberculosis)  and  cancerous. 

Cancer  of  the  peritonaeum  is  usually  secondary  to  similar  disease  of  neigh- 
boring structures.  Primary  instances  have,  however,  been  observed.  The 
secondary  tumors  are  either  metastatic  in  origin  or  the  result  of  spread  by 
contiguity.  The  peritonaeum  is  studded  with  nodules  of  varying  size,  some 
being  so  small  as  to  merit  the  term  miliary,  while  others  are  much  larger, 
the  latter  being  most  abundant  in  Douglas'  pouch  and  in  the  omentum,  which 
often  becomes  hardened  and  firm  and  may  form  an  indurated  tumor  extending 
across  the  upper  abdomen.  Peritonaeal  cancer  occurs  as  epithelial  carcinoma 
and  more  rarely  in  a  diffuse  colloid  form.  The  primary  growths  are  probably 
endotheliomata. 

Symptoms.  The  disease  is  more  common  in  women  and  usually  appears 
late  in  life.  The  clinical  picture  resembles  that  of  chronic  peritonitis  but 
there  is  much  more  evident  cachexia.  Ascites  is  common  and  may  obscure 
the  evidences  otherwise  easily  obtained  by  abdominal  palpation.  In  other 
instances  large  nodules  may  be  plainly  felt  and  there  may  be  a  peritonaeal 
fremitus.     The  retro-peritonaeal  and  inguinal  glands  may  be  enlarged. 


ASCITES.  497 

In  the  presence  of  primary  cancerous  disease  of  other  organs  the  diagnosis 
is  simplified  and  all  possible  seats  of  such  affection,  especially  the  stomach, 
rectum  and  uterus,  should  be  thoroughly  investigated.  In  the  instances  charac- 
terized by  the  miliary  type  of  growth  the  differentiation  from  peritonasal 
tuberculosis  is  difficult.  Aspiration  may  reveal  the  presence  of  haemorrhagic 
fluid  in  either  but  this  manifestation  is  more  typical  of  the  former  condition 
and  microscopic  examination  of  the  fluid  may  reveal  cancer  cells.  The 
fluid  re-accumulates  more  rapidly  in  malignant  tumor,  the  development  of 
cachexia  is  more  rapid  than  in  tuberculosis  and  the  latter  condition  is  more 
frequent  in  the  young.  In  colloid  cancer  there  is  no  ascites  and  a  firm  gelati- 
nous substance  is  present  instead. 

Treatment  is  almost  wholly  symptomatic.  For  the  pain  morphine  is  often 
necessary.  The  bowels  should  be  kept  regularly  active  and  accumu- 
lations of  fluid  which  interfere  with  respiration  and  cardiac  action  should 
be  drawn  off;  repeated  tapping  is  sometimes  indicated. 

Radical  surgical  measures  are  generally  considered  inadvisable,  these  being 
useless,  as  a  rule,  except  in  the  rare  instance  of  single  sarcomatous  growths  of 
the  peritonaeum,  although  instances  have  beenreported  in  which  omental  tumors 
have  been  removed  with  the  result  of  prolonging  life.  Recurrence,  however, 
is  almost  certain  to  take  place. 

.  ASCITES. 

Synonym.     Hydroperitonaeum. 

Definition.     A  collection  of  serous  fluid  in  the  peritonaea!  cavity. 

Etiology.  Ascites  is  rather  a  symptom  than  a  disease  and  occurs  directly 
as  the  result  of  any  condition  causing  interference  with  the  return  of  venous 
blood  through  the  portal  circulation,  such  as  hepatic  disease,  particularly 
cirrhosis;  tumor  or  inflammation  in  the  gastro-hepatic  omentum  or  hilum  of 
the  liver  pressing  upon  the  portal  vein;  abdominal  tumors  of  any  character 
which  exert  pressure  upon  this  vessel;  inflammations  of  the  peritonaeum  of 
any  character.  Ascites  is  also  observed  in  connection  with  chronic  interstitial 
pneumonia,  chronic  pleuritic  and  pericardial  adhesions  and  pulmonary 
emphysema.    It  is  a  prominent  symptom  in  panserositis. 

Of  the  general  causes  of  ascites  chronic  valvular  disease  of  the  heart  is  the 
most  important;  here  the  hydroperitonaeum  occurs  as  a  part  of  a  diffuse 
anasarca  or,  more  rarely,  by  itself;  in  such  instances  there  is  probably  some 
lesion  in  the  liver  which  must  be  held  responsible.  In  chronic  nephritis  and 
conditions  characterized  by  extreme  anaemia,  ascites  is  frequently  a  prominent 
symptom. 

Symptoms.     There  is  gradual  progressive  increase  in  the  size  of  the  abdo- 
men and  with  the  accumulation  of  a  considerable  quantity  of  fluid — 8  to  lo 
quarts  (litres) — typical  physical  signs  become  evident. 
32 


498         DISEASES    OF    THE    DIGESTIVE    SYSTEM    AND    PERITONEUM. 

Inspection  reveals  a  distention  of  the  abdomen;  this  is  pendulous  when 
the  patient  stands  and  is  flattened  and  widened  when  he  lies  upon  his  back. 
If  there  is  a  large  amount  of  fluid  the  abdominal  parietes  are  tense  and  the 
vertical  lines  (linem  alhicantes)  which  are  seen  upon  the  pregnant  abdomen 
are  often  present.  The  superficial  veins  are  distended  and  prominent  and 
if  there  is  marked  obstruction  to  the  portal  circulation  there  may  be  a  varicose 
condition  of  the  veins  about  the  umbilicus  (the  caput  MeduscB).  There  may 
be  accompanying  oedema  of  other  parts  of  the  body,  particularly  the  lower 
limbs.  ', 

Palpation  reveals  the  presence  of  a  fluid  wave  which  is  determined  by  placing 
one  palm  against  one  side  of  the  abdomen  and  tapping  the  other  with  the  fingers 
of  the  opposite  hand.  In  order  to  avoid  mistakes  which  may  occur  in  fat 
subjects  the  ulnar  border  of  the  hand  of  a  second  observer  may  be  placed  verti- 
cally in  the  mid-line  of  the  abdomen;  this  prevents  the  transmission  of  any 
false  wave-like  sensation.  Palpation  of  the  solid  viscera  is  often  difi&cult 
and  is  best  accomplished  by  applying  only  the  finger-tips  to  the  overlying 
skin  and  suddenly  depressing  them,  thus  displacing  the  fluid  and  allowing 
contact  with  the  organ  to  be  appreciated. 

Percussion  elicits  flatness  over  the  fluid  which  falls  back  into  the  flanks 
when  the  patient  is  upon  his  back,  while  over  the  floating  intestines  which 
rise  to  the  surface  tympany  is  present.  By  causing  the  patient  to  roll  to  one 
side  or  the  other  a  tympanitic  note  may  be  demonstrated  in  the  flank  which  is 
uppermost,  showing  that  the  fluid  is  movable  and  consequently  flows  into 
the  lowest  portion  of  the  abdomen.  In  small  collections  the  tympanitic  note 
over  the  middle  of  the  abdomen  becomes  flat  if  the  patient  is  put  in  the  knee- 
elbow  position. 

The  diagnosis  of  ascites  sometimes  offers  difficulties;  the  most  impor- 
tant conditions  to  be  differentiated  are: 

Ovarian  cyst.  Here  the  enlargement  of  the  abdomen  begins  low  on  one 
side  and  rises  toward  the  center.  The  percussion  note  is  flat  here  and  tym- 
panitic in  the  flanks  whither  the  intestinal  coils  have  been  depressed.  Vaginal 
examination  is  usually  helpful  in  differentiation.  The  changes  in  the  charac- 
ter of  the  percussion  note  are  sHght  and  quite  different  from  those  obtaining 
in  ascites.  The  fluid  of  ascites  is  usually  clear,  of  a  specific  gravity  of  about 
1,012  and  contains  a  little  albumin  and  a  few  white  blood  cells,  while  that  of 
ovarian  tumor  is  dark,  viscid,  is  higher  in  specific  gravity,  contains  much 
albumin  and  cholesterin  with  granular  cells  of  two  types,  fatty  and  pale. 
Bloody  fluid  is  rather  characteristic  of  cancerous  ascites;  it  is  less  common  in 
tuberculosis  and  rare  in  hepatic  cirrhosis. 

Chylous,  milky  fluid  is  found  at  times;  true  chyle  is  due  to  the  leakage  into 
the  peritonaeal  cavity  of  the  contents  of  the  thoracic  duct.  Fatty  fluid,  resem- 
bling chyle  but  which  under  the  microscope  shows  the  presence  of  fat  globules, 


ASCITES. 


499 


occurs  in  some  forms  of  cancer  of  the  peritonseum.  Chylous  ascites  has  been 
observed  in  filariasis  and,  in  mild  type,  in  patients  with  lipaemia  resulting  from 
continued  milk  diet. 

The  distended  bladder  may  be  mistaken  for  ascites  but  there  is  usually  a 
characteristic  history,  the  urine  dribbles  and  the  condition  may  be  absolutely 
differentiated  by  catheterization. 

Hydronephrosis  of  extreme  degree  may  be  confounded  with  ascites  but  the 
former  condition  is  slow  in  evolution,  there  are  usually  symptoms  referable 
to  the  kidney  and  the  tumor  is  usually  first  noticed  on  one  side  of  the  mid-line. 

Cysts  of  the  omentum  or  pancreas,  and  hydatid  cysts  of  the  abdomen 
sometimes  resemble  collections  of  ascitic  fluid. 

Treatment  depends  upon  the  cause  of  the  condition  and  for  a  discussion 
of  the  management  of  symptomatic  ascites  the  reader  is  referred  to  the  sections 
upon  the  treatment  of  cardiac,  hepatic  and  renal  disease.  Tapping  is  often 
indicated  to  relieve  the  patient's  discomfort  and  repetition  of  the  operation 
may  become  necessary.  The  technique  of  Ihe  procedure  has  been  fully 
described  in  the  section  upon  the  treatment  of  cirrhosis  of  the  liver.  Diminu- 
tion of  the  chlorides  of  the  diet,  as  outlined  in  the  section  upon  the  management 
of  the  dropsy  of  chronic  nephritis,  may  be  effectual  in  relieving  the  tendency 
to  ascites. 


500 


DISEASES    OF    THE    BLOOD. 


CHAPTER  V. 
DISEASES  OF  THE  BLOOD. 

THE  ANEMIAS. 
SECONDARY  ANEMIA. 

Synonym.     Symptomatic  Anaemia. 

Secondary  Anaemia  is  the  most  common  of  the  different  types  of  blood 
poverty  and  occurs  in  various  forms  which  may  be  best  classified  in  accor- 
dance with  their  causation. 

a.  AncBmia  following  hemorrhage.  This  type  is  observed  as  a  result 
of  loss  of  blood  following  traumatism,  post-partum  haemorrhage,  haemorrhage 
from  the  lungs,  stomach  or  intestines,  aneurysmal  rupture,  haemophilia,  pur- 
pura, uncinariasis  or  hook-worm  disease  and  other  parasitic  affections,  such 
as  the  presence  of  distoma  hcBmatobium  in  the  kidney. 

Haemorrhage  from  these  causes,  if  sufficiently  large,  may  cause  death  but 
in  less  severe  instances  the  watery  and  saline  constituents  of  the  blood  are 
quickly  made  up  by  absorption  from  the  alimentary  tract.  Restoration  of 
the  albuminous"  substances  is  also  rapid  but  a  considerably  longer  time,  even 
several  months,  may  be  necessary  to  complete  restoration  of  the  corpuscles 
and,  more  especially,  of  the  haemoglobin. 

b.  AncBmia  resulting  from  the  continued  drain  of  chronic  disease.  Such 
conditions  as  chronic  nephritis,  malignant  growths,  protracted  suppuration 
or  lactation,  chronic  diarrhoeas  and  malaria,  produce  anaemia  as  a  result  of 
their  continued  drain  upon  the  albuminous  constituents  of  the  blood. 

c.  Inanition  anamia  is  produced  by  a  lack  of  sufficient  food  and  by  con- 
ditions which  prevent  the  ingestion,  digestion  or  assimilation  of  food  when 
there  is  no  interference  with  the  supply.  It  appears  in  such  conditions  as 
cancer  of  the  oesophagus  or  of  the  stomach,  where  there  is  also  additional 
anaemia  due  to  the  presence  of  the  malignant  growth,  and  in  chronic  digestive 
and  assimilative  disorders. 

d.  Toxic  ancemia  results  from  the  presence  in  the  circulation  of  such  poison- 
ous substances  as  lead,  arsenic  and  mercury  and  may  be  observed  in  workers 
in  paint,  plumbers  and  type  setters  and  in  upholsterers  and  decorators.  The 
organic  toxins  of  syphilis  and  malaria  are  potent  factors  in  the  causation  of 
this  type  of  anaemia  as  are  also  those  of  the  infectious  diseases  including 


SECONDARY    ANEMIA.  501 

tuberculosis.  These  poisonous  substances  directly  destroy  the  blood-corpus- 
cles in  some  instances  while  in  others  they  act  by  increasing  the  rapidity  of 
their  ordinary  destruction. 

Symptoms.  Usually  in  secondary,  as  in  other  forms  of  anaemia,  the  skin, 
and  particularly  the  mucous  membranes,  are  pale  but  it  is  not  unusual  to 
observe  the  pallor  and  upon  examination  of  the  blood  to  find  no  marked  poverty 
of  the  blood;  likewise  both  skin  and  mucous  membranes  may  appear  normal 
in  color  when  anaemia  is  present.  Faintness,  cardiac  palpitation  and  dys- 
pnoea on  exertion  are  common. 

Physical  examination  of  the  heart  and  vessels  often  reveals  the  presence  of 
various  functional  or  haemic  murmurs.  These  are  of  three  types.  The  most 
common  is  the  so-called  bruit  du  diable  or  humming  top  miurmur.  This, 
like  other  haemic  murmurs,  is  ventriculo-systolic  in  time  and  is  heard  at  the 
root  of  the  neck  when  the  head  is  turned  to  the  left.  It  is  musical  in  quality 
and  resembles — as  its  designation  signifies — the  sound  produced  by  a  hum- 
ming top;  it  is  caused  by  the  eddy  produced  by  the  current  of  thinned  blood 
rushing  from  a  large  to  a  smaller  vessel.  Less  frequently  a  ventriculo-systolic 
murmur  of  soft  blowing  quality  is  heard  over  the  pulmonic  area  and  still 
more  rarely  a  ventriculo-systolic  murmur  is  audible  at  the  cardiac  apex. 
This  last  bruit  is  due  to  a  relaxation  of  the  mitral  ring  resulting  from  weakness 
of  the  heart  muscle  caused  by  poor  cardiac  nutrition.  The  condition  pro- 
duced is  a  true  relative  insufficiency  of  the  mitral  valve.  Of  course  it  is  quite 
possible  for  two  or  even  all  three  of  these  murmtirs  to  co-exist  in  the  same 
patient. 

These  murmurs,  strangely  enough,  afford  a  fairly  reliable  means  of  estimat- 
ing the  haemoglobin  percentage  of  the  blood.  When  the  first  type  of  murmur 
is  heard  the  blood  probably  contains  about  80  percent,  of  haemoglobin,  in 
the  presence  of  the  second  variety  of  bruit,  about  60  percent,  and  when  the 
third  form  is  detected,  about  40  to  50  percent. 

Examination  of  the  blood  shows  a  reduction  in  the  number  of  the  red  cells 
(the  normal  being  about  5,000,000  per  cubic  millimeter)  and  a  reduction  in  the 
percentage  of  haemoglobin  rather  in  excess  of  that  of  the  number  of  red  corpus- 
cles. After  haemorrhage  the  average  size  of  the  red  cells  may  be  slightly 
reduced,  their  color  is  noticeably  pale  and  a  moderate  number  of  poikilocytes 
may  be  noted.  Soon  after  the  haemorrhage  nucleated  red  cells  and  free 
nuclei  appear  in  the  blood.  The  leucocytes  are  moderately  increased  in 
number,  especially  the  polynuclear  neutrophiles  while  the  small  mono- 
nuclear lymphocytes  are  relatively  diminished.  .  As  the  condition  of  the 
blood  returns  to  normal  the  leucocytosis  gradually  diminishes.  The  haemo- 
globin percentage  is  somewhat  lower  than  that  of  the  red  cells. 

In  anaemia  due  to  chronic  disease,  the.  blood  changes  are  similar  to  those 
described  above,'  but  the  poikilocytosis  may  be  more  extreme;  the  nucleated 


502  DISEASES    OF    THE    BLOOD. 

red  cells  are  generally  few  and  large  nucleated  corpuscles  containing  kary- 
okinetic  figures  may  be  found.  There  is  usually  a  leucocytosis  but  in  very 
persistent  chronic  conditions  the  white  blood  cells  may  be  diminished. 

The  blood  of  inanition  anasmia  is  characterized  by  a  relative  diminution 
of  the  plasma  over  that  of  the  red  corpuscles. 

The  diagnosis  is  usually  easily  made  from  the  history  of  the  patient  and 
from  the  existence  of  one  of  the  causes.  In  doubtful  instances  examination 
of  the  blood  will  show  the  characteristic  diminution  of  red  cells  and  haemoglobin 
in  nearly  equal  proportion  and  the  cellular  changes  described  above. 

Treatment.  In  anaemia  following  traumatism  usually  little  is  needed  in 
the  way  of  treatment  save  rest  and  plenty  of  nutritious  food.  Fresh  air 
is  essential  and  if  the  patient  is  confined  to  bed  he  should  be  placed  in  a  freely 
ventilated  room  to  which  the  sun  has  sufficient  access.  The  administration 
of  iron,  although  often  unnecessary,  may  hasten  recovery  which  frequently 
is  surprisingly  rapid. 

The  anaemia  of  chronic  disease  is  more  difficult  of  treatment  and  is  usually 
impossible  of  cure  without  removal  of  the  primary  cause.  Here  nourishing 
food  is  necessary  and  one  should  not  hesitate  to  allow  a  proper  mixed  diet 
even  to  the  patient  afflicted  with  chronic  nephritis.  Plenteous  food  is  also 
a  requirement  of  the  sufferer  from  inanition  and  attempts  should  be  made 
to  render  the  alimentary  tract  capable  of  digesting  and  assimilating  the  same, 
for  little  is  accomplished  in  the  way  of  increasing  the  nutrition  of  the  patient 
until  this  is  done.  Iron  vitellin  in  half  ounce  (15.0)  doses  materially  accel- 
erates the  cure. 

Toxic  anaemia  necessitates  the  removal  of  the  poisonous  substances  from 
the  organism  (see  the  sections  upon  lead,  mercurial  and  arsenic  poisoning 
and  also  those  upon  syphilis  and  malaria)  and,  as  in  preceding  types  of  the 
condition,  the  administration  of  plenty  of  good  food  and  of  iron.  In  sec- 
ondary anaemia  this  substance  may  be  given  in  any  of  the  various  prepara- 
tions suggested  under  the  treatment  of  chlorosis  (p.  504),  and,  as  in  the  latter 
disease,  arsenic  is  often  a  useful  adjunct. 

In  malarial  patients  who  continue  to  exhibit  the  symptoms  of  chronic 
malarial  poisoning  it  is  necessary  to  rid  the  blood  of  plasmodia  before  treat- 
ment of  the  anaemia  will  prove  effectual.  In  such  instances  the  organisms 
are  often  secluded  in  the  spleen  where  they  seem  to  enjoy  a  certain  immunity 
to  quinine  as  ordinarily  administered  but  if  the  fluidextract  of  ergot  in  doses 
of  I  drachm  (4.0)  twice  a  day  is  given,  the  dosage  being  increased  until  the 
rate  of  the  heart  is  slowed  and  the  blood  pressure  increased,  a  physiological 
squeezing  of  the  spleen  follows  and  the  plasmodia  are  forced  into  the  circu- 
lation to  become  an  easy  prey  to  quinine  which  is  best  given  hypodermatically 
in  the  form  of  the  carbamide,  20  to  30  grains  (1.33  to  2.0)  in  aqueous 
solution. 


CHLOROSIS.  503 

PRIMARY  OR  ESSENTIAL  AN.EMIAS. 
Chlorosis. 

Synonyms.     Chlorasmia;  Chloranaemia. 

Definition.  An  anaemia  characterized  by  a  relative  diminution  of  the 
hcemoglobin  in  the  blood  and  most  frequently  observed  in  girls  and  young 
women. 

etiology.  "While  the  direct  causation  of  chlorosis  is  unknown  there  are 
certain  well-recognized  facts  to  be  stated  concerning  the  incidence  of  the  disease. 
It  occurs  almost  exclusively  in  the  female  sex,  some  clinicians  definitely 
stating  that  they  have  never  observed  an  instance  in  the  male;  it  is  most  fre- 
quent between  the  ages  of  13  and  17  although  it  may  appear  both  earlier  and 
later  than  these  limits.  Climatic  influence  is  not  a  factor  in  its  causation 
but  it  seems  to  be  more  common  in  blondes  than  in  brunettes. 

Predisposing  factors  are  insufficient  food,  lack  of  fresh  air,  unhygienic 
surroundings,  over-work,  menstrual  disorders,  excessive  emotion,  especially 
of  sexual  character,  and  such  hereditary  influences  as  tuberculous  disease. 
The  wearing  of  too  tightly  laced  corsets  has  been  held  responsible  and  the 
affection  may  be  associated  with  developmental  defects  of  the  circulatory 
and  generative  systems.  It  has  been  suggested  that  chlorosis  is  the  result 
of  constipation  and  intestinal  putrefaction,  toxic  substances  being  absorbed 
from  the  alimentary  tract  which  interfere  with  the  development  of  the  red 
blood  cells. 

Pathology.  Aside  from  the  blood  changes  the  affection  has  no  character- 
istic pathology;  the  developmental  defects  sometimes  observed  in  the  heart, 
blood-vessels  and  genitalia  are  probably  adventitious. 

Symptoms.  The  skin  is  of  a  peculiar  and  characteristic  yellowish-green  hue 
which  has  given  rise  to  the  name  of  the  disease;  pigmented  spots  over  the 
joints  and  other  parts  may  be  observed  and  in  mild  instances  there  may  be 
a  slight  redness  of  the  cheeks,  particularly  after  exercise.  The  patient  com- 
plains of  weakness,  dyspnoea  on  exertion  and  a  tendency  to  faint;  vertigo, 
cardiac  palpitation  and  irregularity  may  be  present.  Functional  cardiac 
murmurs  such  as  those  described  on  p.  501  may  be  audible;  the  pulse  is 
soft  and  full  and  there  may  be  pulsation  of  the  veins  of  the  neck  and  of  other 
superficial  veins.  Venous  tlirombosis  may  occur.  The  face  is  often  swollen 
and  the  ankles  may  become  oedematous;  the  extremities  are  frequently  cold. 
The  patient  is  often  despondent  and  easily  irritated.  Neuralgic  headaches 
and  menstrual  disturbances,  which  are  usually  rather  a  manifestation  of  the 
affection  than  a  factor  in  its  causation,  are  common.  A  febrile  movement 
of  slight  degree  may  be  noted. 

The  patient's  appetite  is  often  depraved  and  she  craves  acid  foods  or  even 


504  DISEASES    OF    THE    BLOOD. 

various  indigestible  substances  such  as  chalk.  Gastric  hyperacidity  is 
common  and  constipation  very  frequent.  The  association  of  chlorosis, 
especially  in  subjects  who  are  prone  to  wear  tight  corsets,  with  gastroptosis, 
enteroptosis  and  nephroptosis  has  been  observed  in  numerous  instances. 
The  patient  as  a  rule  is  well-nourished. 

The  Blood.  The  characteristic  changes  in  this  fluid  are  of  the  utmost 
importance  in  the  diagnosis  of  the  affection.  The  red  cells  are  only  moder- 
ately diminished  in  number — 3,500,000  to  4,500,000  per  cubic  millimeter — 
while  the  diminution  of  the  percentage  of  haemoglobin  is  proportionately 
much  greater — 40  to  50  percent. — consequently  the  haemoglobin  index  (the 
relative  proportion  between  the  haemoglobin  percentage  and  the  number  of 
red  corpuscles)  is  low.  This  feature,  while  not  absolutely  constant,  is  typical 
of  chlorosis  and  is  observed  in  no  other  variety  of  anaemia.  With  the  dim- 
inution of  the  haemoglobin  the  iron  content  of  the  blood  is  diminished,  the 
alkalinity  of  the  fluid  is  increased  and  its  color  becomes  noticeably  lighter. 
Microscopically  the  red  cells  are  of  lighter  color  than  normal  and  may  be 
somewhat  changed  in  shape.  Poikilocytosis  is  usually  present  and  in  extreme 
instances  of  the  disease  may  be  marked.  Large  red  blood  cells  (megalocytes) 
may  be  observed  in  small  number  but  the  average  size  of  the  red  corpuscles 
is  likely  to  be  below  normal.  Some  nucleated  red  cells  may  be  noted.  The 
number  of  white  cells,  as  a  rule,  is  close  to  the  normal  or  very  slightly  increased. 

The  diagnosis,  when  proper  methods  are  employed,  is  usually  easy  and 
may  be  made  upon  the  characteristic  appearance  of  the  patient.  Important 
points  are  the  greenish-yellow  tinge  of  the  skin  and  the  bluish-white  color 
of  the  sclerotics.  Tuberculosis  may  be  ruled  out  by  physical  examination 
of  the  lungs,  and  cardiac  disease  by  auscultation  of  the  heart,  while  urinary 
examination  will  differentiate  the  disease  from  renal  affections.  Blood 
examination  will  clinch  the  diagnosis  and  enable  the  physician  to  rule  out 
other  forms  of  anaemia. 

The  prognosis  is  favorable  under  proper  treatment  although  months  may 
be  necessary  before  a  complete  recovery  is  established. 

Treatment.  In  the  treatment  of  chlorosis  iron  is  essential.  Of  the  prepara- 
tions of  this  substance  there  are  two  main  groups,  the  inorganic  and  the  massed, 
,  this  term  being  applied  to  irons  in  inorganic  combination,  which  are  not  dis- 
sociated by  the  gastric  juice.  The  great  objection  to  all  the  inorganic  irons 
is  that  upon  contact  with  the  hydrochloric  acid  of  the  gastric  juice  they  are 
converted  into  iron  chloride.  Even  haemoglobin  and  all  other  blood  irons 
undergo  this  change,  and  while  the  action  of  iron  chloride  in  chlorosis  is  bene- 
ficial it  has  certain  disadvantages.  This  salt,  when  taken  into  the  mouth, 
exercises  an  injurious  action  upon  the  teeth;  it  is  irritant  to  the  stomach; 
it  causes  constipation.  These  disadvantages  we  may  overcome  by  giving 
iron  in  the  same  form  in  which  it  occurs  in  the  food  and  consequently  a  massed 


CHLOROSIS.  505 

iron  must  be  employed.  In  the  present  state  of  our  knowledge  of  the  chem- 
istry and  therapeutics  of  iron  the  necessary  qualifications  which  an  accept- 
able iron  compound  should  possess  are: 

a.  It  must  be  in  definite  chemical  organic  combination. 

b.  It  must  be  able  to  resist  the  action  of  the  free  hydrochloric  acid  of  the 
gastric  juice  without  becoming  decomposed  with  the  formation  of  iron  chloride 
which  has  been  demonstrated  to  coagulate  the  gastric  mucosa,  cause  locaHzed 
necrosis  and  produce  inflammatory  exudation. 

c.  It  must  not  interfere  with  digestion. 

d.  It  must  not  be  irritating  nor  astringent. 

e.  It  must  show  definite  results  in  (i)  an  increase  of  the  number  of  red 
blood  cells  and  (2)  in  the  amount  of  contained  haemoglobin. 

At  first  sight  hEemoglobin,  when  administered  by  mouth,  would  seem  to  be  a 
proper  organic  iron  for  exhibition  in  anaemia  and  allied  conditions;  as  a  matter 
of  fact,  however,  Cloetta  as  early  as  1896  showed  that  it  is  not  absorbed  as  such 
but  is  destroyed  as  soon  as  it  enters  the  stomach.  With  this,  the  theory  of 
the  advantage  of  blood,  or  products  made  from  blood,  for  oral  administra- 
tion, falls.  The  crucial  test  for  the  actual  massed  iron  preparation  is  that 
of  MacCallum.  Briefly,  a  small  quantity  of  J  to  i  percent,  solution  of  haema- 
toxylin  is  added  to  the  suspected  iron  compound.  If  the  iron  is  inorganic, 
a  characteristic  blue-black  color  is  produced;  if  the  iron  is  organic  or  massed 
no  color  reaction  results.  That  many  so-called  organic  iron  compounds  are 
practically  only  combinations  of  iron  salts  with  albuminoids  is  readily  demon- 
strated by  the  addition  to  them  of  a  few  drops  of  silver  nitrate  solution,  which 
will  cause  a  precipitation  of  these  albuminoids. 

The  solution  of  iron  vitellin,  marketed  as  ovoferrin,  is  a  definite  true  organic 
iron  compound  in  that  it  complies  with  all  the  requirements  given  above  and 
is  applicable  in  all  instances  where  a  massed  iron  is  desired.  Its  usual  dosage 
is  ^  an  ounce  (15.0)  3  times  daily  before  meals,  and  it  is  the  most  satisfactory 
form  of  administering  this  important  element. 

In  instances  where  the  susceptibility  of  the  stomach  does  not  preclude  their 
administration,  increasing  doses  of  the  astringent  salts,  especially  iron  sulphate 
and  chloride  may  be  given  to  advantage.  Large  quantities  of  these  salts  are 
often  well  borne,  but  it  must  be  remembered  that  considerable  amounts  of 
the  sulphate  have  been  known  to  cause  intestinal  obstruction.  When  they 
produce  untoward  effects  they  should  be  replaced  by  other  preparations, 
preferably  the  most  astringent  ones  which  the  stomach  will  tolerate.  The 
astringent  iron  compounds  lose,  to  some  extent,  their  styptic  taste  when  com- 
bined with  glycerin,  which  also  has  the  effect  of  reducing  some  of  the  ferric 
to  a  ferrous  salt.  To  restore  the  haemoglobin  and  red  blood  cells  small  doses 
of  reduced  iron — i  to  2  grains  (0.065  ^o  0.13) — of  the  carbonate  or  of  some 
one  of  the  combinations  with  vegetable  acids  are  usually  the  most  serviceable. 


5o6  DISEASES    OF    THE    BLOOD. 

As  the  scale  preparations  rarely  disagree  they  may  be  used  for  patients  with 
weak  digestions  and  in  small  doses  can  usually  be  continued  for  indefinite 
periods.  Oftentimes  in  chlorosis  better  results  are  obtained  from  iron  with 
strychnine  or  arsenic  than  from  iron  alone,  the  syrup  of  iron,  quinine  and 
strychnine  phosphate,  the  elixir  of  iron,  strychnine  and  quinine  of  the  National 
Formulary  and  the  pill  of  the  three  phosphates  which  contains  i  grain  (0.065) 
of  quinine,  gV  of  a  grain  (0.002)  of  strychnine,  ij  minims  (o.io)  of  concen- 
trated phosphoric  acid  and  licorice  powder  to  5  grains  (0.33)  being  useful 
preparations.  Iron  arsenate  |  to  jq  of  a  grain  (0.008  to  0.006)  is  an  excel- 
lent remedy  in  chlorosis.  Iron  may  also  be  given  hypodermatically  when 
gastric  disorders  preclude  its  exhibition  by  the  mouth.  The  following  for- 
mula may  be  employed:  Iron  and  ammonium  citrate,  75  grains  (5.0),  sodium 
arsenate  f  of  a  grain  (0.048),  sterilized  water  to  12J  drachms  (50.0),  15  to  30 
minims  (i.o  to  2.0)  daily  to  be  injected  into  the  muscles  of  the  shoulder  or 
buttock.  Usually  the  use  of  iron  must  be  persisted  in  for  a  period  of  several 
months  and  it  may  be  necessary  to  continue  the  treatment,  the  doses  being 
diminished,  for  even  longer  periods.  Recurrences  of  the  chlorosis,  which 
are  not  uncommon,  necessitate  a  renewal  of  treatment.  With  regard  to 
manganese  in  anaemic  conditions  it  may  be  definitely  stated  that  as  a  regen- 
erator of  the  haemoglobin  and  red  cells  it  is  absolutely  inert. 

The  importance  of  proper  treatment  for  the  accompanying  constipation 
cannot  be  over-rated.  The  daily  administration  of  a  mild  saline  purge  is 
often  indicated  and  in  obstinate  instances  the  condition  should  be  treated 
as  advised  in  the  section  upon  the  treatment  of  constipation. 

Gastric  disorders  such  as  hj^ochlorhydria,  etc.,  should  receive  appropriate 
treatment.  The  administration  of  dilute  hydrochloric  acid  in  10  drop  (0.66) 
doses  in  a  glass  of  water  to  be  taken  with  meals  is  advised  in  conditions  of  low 
gastric  acidity,  the  acid  being  useful  in  dissolving  the  iron  as  well  as  in  cor- 
recting the  secretory  abnormality. 

The  theory  has  been  advanced  by  Bunge  that  intestinal  fermentation  by 
producing  sulphides  interferes  with  the  proper  absorption  of  the  iron  of  the 
food  and,  in  order  to  prevent  this  decomposing  process,  it  is  suggested  that  in 
connection  with  other  treatment,  it  is  well  to  render  the  intestinal  contents  as 
nearly  aseptic  as  possible  by  giving  such  intestinal  antiseptics  as  bismuth  naph- 
tholate — 5  grains  (0.33) — 3  times  a  day  or  sodium  glycocholate  ^  grain  (0.032), 
with  a  little  menthol  to  prevent  distressing  eructations,  at  similar  intervals. 
The  absence  of  intestinal  decomposition  is  shown  by  testing  the  urine  for 
indican  and  the  disappearance  of  the  sulphides  from  the  stools  by  giving 
bismuth  subnitrate  which,  in  the  presence  of  these  substances,  causes  the 
fasces  to  assume  a  black  color. 

In  connection  with  the  drug  treatment  of  anaemia  the  diet  and  general 
hygiene  of  the  patient  should  also  be  considered.     Rest  in  bed  is  important, 


PROGRESSIVE    PERNICIOUS   ANEMIA.  507 

particularly  in  severe  instances,  and  plenty  of  good  easily  digestible  food  should 
be  allowed.  The  foods  which  contain,  iron,  such  as  fish,  spinach,  apples,  oats, 
beef,  lentils,  strawberries,  beans,  potatoes,  eggs,  wheat,  rye,  veal,  milk,  rice, 
etc.,  should  be  eaten  in  abundance  and  the  red  wines,  and  natural  chalybeate 
waters  such  as  those  of  La  Bourbole,  Levico,  Flit  wick,  and  the  Columbian 
Spring,  Saratoga,  may  prove  useful.  As  the  haemoglobin  becomes  increased 
the  patient  may  be  allowed  to  sit  up  for  a  little  time  each  day  until  finally 
she  remains  up  all  day.  During  this  period  massage  may  be  employed  to 
advantage  as  well  as  mild  hydrotherapeutic  measures,  tepid  sponging,  douching 
and  the  like.  For  a  considerable  period  after  being  out  of  bed  the  patient 
should  not  be  allowed  to  tire  herself  but  as  strength  returns  she  may  be  per- 
mitted to  indulge  in  the  milder  forms  of  exercise.  Sea  voyages  and  a  change 
of  climate,  particiilarly  a  sojourn  at  the  sea  side,  will  materially  benefit  the 
patient's  condition  during  convalescence. 

Progressive  Pernicious  Anaemia. 

Definition.  A  chronic  anaemia  characterized  by  a  marked  diminution  of 
the  red  blood  cells  and  a  relatively  high  haemoglobin  content. 

.Etiology.  The  disease  is  rather  rare  in  the  United  States.  It  appears 
to  affect  males  rather  more  commonly  than  women  and  usually  appears  after 
the  incidence  of  middle  age  but  has  been  observed  in  young  adults  and  in 
children. 

Its  actual  causation  has  not  been  definitely  determined;  in  some  instances 
it  appears  during  pregnancy  but  may  occur  after  delivery  and  during  lacta- 
tion as  well.  The  anaemia  caused  by  certain  intestinal  parasites,  particularly 
the  bothriocephalus  latus  and  the  anchylostomum  duodenale  is  often  of  the  pro- 
gressively pernicious  type,  and  as  other  causes,  severe  and  protracted  digestive 
disorders  and  gastric  atrophy  may  be  mentioned.  StiU  another  type  of  the 
disease  occurs  idiopathically  without  previous  haemorrhage,  renal,  tubercu- 
lous, diarrhoeal,  malignant  or  other  disease  and  attributable  to  no  discoverable 
cause.  The  condition  of  the  blood  which  obtains  in  pernicious  anaemia  has 
been  considered  as  resulting  from  haemolysis  with  an  accumulation  of  iron 
in  the  liver  and  an  abnormal  increase  of  the  urobilin  of  the  urine.  The 
destruction  of  the  blood  cells  is  believed  by  the  adherents  of  the  theory  of 
increased  haemolysis  to  be  due  to  the  absorption  of  toxic  substances  generated 
as  a  result  of  improper  performance  of  the  digestive  function.  Other  theorists 
hold  that  small  internal  capillary  haemorrhages  are  in  great  measure  re- 
sponsible for  the  disease,  while  stiU  others  consider  that  it  is  due  to  a  faulty 
haemogenesis  which  turns  out  red  cells  of  poor  powers  of  resistance. 

Pathology.  The  usual  hue  of  the  skin  is  suggestive  of  that  of  the  lemon, 
the  fat  is  light  yellow  and  the  voluntary  muscles  are  distinctly,  even  abnormally 


5o8  DISEASES   OF    THE    BLOOD. 

red.  The  heart  muscle  is  yellowish  from  its  infiltration  of  fat.  The  stomach 
may  be  normal  but  in  certain  instances  an  atrophy  of  the  gastric  tubules 
has  been  observed.  Enlargement  and  fatty  degeneration  of  the  liver  are 
common  and  in  the  liver  cells  of  the  outer  and  middle  zones  of  the  lobules 
iron  is  deposited  which  may  be  distributed  in  such  a  manner  as  to  outline 
the  bile  capillaries.  This  deposition  of  iron  in  the  hepatic  cells  has  been 
considered  characteristic  of  pernicious  anaemia.  The  spleen  may  contain 
iron  in  excess  and  may  be  smaller  than  normal  but  these  changes  are  not 
constant.  The  kidneys  also  may  show  an  increased  quantity  of  iron.  The 
bone-marrow  is  dark  red,  its  lymphoid  cells  are  increased  in  number  and 
it  contains  many  nucleated  red  blood  cells  especially  megalo-  or  giganto- 
blasts.     Eosinophiles  and  neutrophiles  are  also  present. 

Associated  changes  in  the  nervous  system,  such  as  alterations  in  the  cells 
of  the  posterior  columns  of  the  cord  and  softening  of  the  upper  portion  of  the 
lumbar  cord,  have  been  described. 

Symptoms.  The  onset  of  the  disease  is  gradual  and  may  be  preceded  by 
symptoms  of  digestive  disorder.  The  patient  notices  an  increasing  weakness 
finally  becoming  extreme  even  to  prostration;  accompanying  the  physical 
debility  there  is  usually  progressive  distaste  for  mental  exertion.  The  main- 
tenance of  body  weight  is  remarkable  and  characteristic,  emaciation  being  a 
rare  manifestation.  The  skin  assumes  the  typical  lemon-yellow  tinge  which 
in  extreme  degrees  simulates  that  of  jaundice.  The  yellow  color  is  usually 
preceded  by  pallor  and  may  be  absent  in  certain  instances.  A  pigmentation 
resembling  that  of  Addison's  disease  is  often  observed,  usually  occurring  as 
a  result  of  the  administration  of  arsenic.  Patches  of  leucoderma  may  be 
noted.  The  sclerotics  are  usually  pearly  white.  The  mucous  membranes 
are  markedly  pale. 

Digestive  symptoms  are  frequent;  anorexia,  nausea  and  vomiting  and 
obstinate  diarrhoea  are  the  most  common  of  these. 

A  moderate  febrile  movement  of  irregular  type  it  not  rare.  The  urine  is, 
as  a  rule,  of  low  specific  gravity  and  either  light  or  of  very  dark  color  due  to 
the  presence  of  an  increased  amount  of  urobilin. 

Circulatory  symptoms  are  very  noticeable.  The  pulse  is  large,  full  and 
may  suggest  the  pulse  of  aortic  insufficiency.  The  pulsation  in  the  capil- 
laries is  often  visible  and  visible  pulsation  of  the  arteries  and  even  of  the  veins 
may  occur;  mvirmurs  of  functional  type  (see  p.  501)  are  frequent.  Haemor- 
rhages into  the  skin,  mucous  membranes  or  retinae  may  take  place.  A  tend- 
ency to  fainting  or  to  dyspnoea  on  exertion  is  often  observed. 

Nervous  symptoms,  such  as  numbness  of  the  extremities,  pain  and  the 
symptoms  of  sclerotic  change  in  the  postero-lateral  columns  of  the  cord,  may 
develop. 

The  blood  changes  are  frequently  very  characteristic.     In  color  the  blood 


PROGRESSIVE    PERNICIOUS   ANEMIA.  509 

may  be  quite  pale,  dark  or  normal.  In  consistency  it  is  thin,  the  specific 
gravity  is  reduced  in  extreme  instances  and  coagulation  is  retarded.  As  a 
rule  there  is  great  reduction  in  the  number  of  red  corpuscles,  the  average 
being  not  far  from  1,000,000  per  cubic  millimeter.  Fresh  specimens  reveal 
a  marked  poikilocytosis  and  the  absence  of  any  great  degree  of  rouleau  for- 
mation. The  average  diameter  of  the  red  cells  is  increased,  the  reverse  of 
the  condition  present  in  chlorosis  and  secondary  anaemia.  Large  red  cells 
(macrocytes)  are  often  abundant  even  early  in  the  disease.  Gigantoblasts 
(very  large  nucleated  red  corpuscles)  may  be  present  late  in  the  disease, 
these  are  the  most  abundant  of  the  three  types  of  nucleated  red  cells  which  may 
be  observed,  the  others  being  normoblasts  and  microblasts,  the  latter  being 
usually  few.  The  normoblasts  are,  as  a  rule,  fewer  than  the  megaloblasts, 
while  in  secondary  anasmia  the  opposite  is  the  case.  Red  blood  cells  with 
the  faint  remains  of  nuclei  are  not  uncommon  and  karyokinetic  figures  may 
be  seen  in  the  megaloblasts. 

The  haemoglobin  is  not  diminished  in  proportion  to  the  reduction  in  the 
number  of  red  cells,  the  haemoglobin  index  being  high  in  consequence.  This 
appears  to  be  due  to  the  fact  that  the  megalocytes  contain  a  relatively  greater 
amount  of  haemoglobin  than  does  a  corresponding  number  of  normal  sized 
corpuscles;  this  is  a  characteristic  of  pernicious  anaemia. 

The  leucocytes  are  usually  diminished,  4,000  to  the  cubic  millimeter  being 
a  fair  average.  There  is  a  relative  increase  in  the  lymphocytes  and  a  decrease 
in  the  number  of  polynuclear  neutrophiles. 

The  diagnosis  in  severe  instances  is  easily  made  upon  blood  examination; 
in  milder  instances  the  separation  of  the  disease  from  other  anaemias  is  more 
difl&cult,  points  in  favor  of  pernicious  anaemia  being  the  presence  of  megalo- 
cytes and  megaloblasts,  the  low  leucocytosis  with  lymphocytosis  and  the 
high  haemoglobin  index. 

The  prognosis  is  usually  unfavorable  although  recovery  has  been  observed 
and  temporary  improvement  is  fairly  common.  The  idiopathic  instances 
of  the  disease  usually  do  badly  as  also  do  those  whose  blood  shows  a  large 
number  of  large  nucleated  red  corpuscles.  Digestive  distiurbances  are  un- 
favorable manifestations  and  patients  who  do  not  tolerate  arsenic  well  are 
likely  to  fare  badly. 

Treatment.  The  dietetic,  hygienic  and  massage  treatment  recommended 
for  chlorosis  is  quite  as  important  in  the  management  of  pernicious  anaemia. 
Prolonged  rest  in  bed  is  often  necessary  and  almost  always  advisable;  free 
ventilation  of  the  sick-room  is  to  be  insisted  upon,  in  fact,  if  circumstances 
and  the  weather  permit,  improvement  will  usually  progress  with  greater 
rapidity  if  the  patient's  couch  is  taken  out  of  doors  each  day  for  a  consider- 
able period  of  time. 

The  drug  which  exerts  the  most  favorable  effect  in  pernicious  anaemia  is 


5IO  DISEASES    OF    THE    BLOOD. 

arsenic;  unfortunately,  however,  certain  patients  do  not  bear  it  well  and  fre- 
quently it  tends  to  cause  gastric  disturbances  which  necessitate  its  intermis- 
sion. It  may  be  administered  in  various  forms  of  which  perhaps  the  solution 
of  potassium  arsenite  (Fowler's  solution)  is  to  be  preferred  both  on  account 
of  the  resiilts  obtained  by  its  use  and  its  convenience.  Increasing  doses  are 
usually  prescribed,  beginning  with  3  or  4  minims  (0.20  to  0.25)  3  times  a 
day,  well  diluted  and  after  meals.  This  dose  should  be  gradually  increased 
by  I  minim  (0.065)  every  week  or  10  days  until  20  to  30  minims  (1.33  to  2.0) 
thrice  daily  are  reached.  If  well  borne  the  patient  should  be  advised  to  con- 
tinue the  medication  until  marked  improvement  is  noticed.  Should  symp- 
toms of  gastric  irritation  appear  the  arsenic  should  be  immediately  stopped, 
to  be  resumed  as  soon  as  the  untoward  manifestations  disappear.  Arsenic 
may  also  be  prescribed  in  the  form  of  arsenic  trioxide,  or  as  sodium  or  iron 
arsenate  in  the  ordinary  doses  gradually  increased.  If  the  digestive  disturb- 
ance caused  by  the  administration  of  the  arsenic  by  mouth  is  obstinate  or 
if  the  exhibition  of  the  drug  by  mouth  is  barred  for  any  other  reason  we  may 
have  recourse  to  hypodermatic  injections.  Fowler's  solution  mixed  with 
twice  its  bulk  of  sterile  water  may  be  given  by  this  method  in  little  less  than 
the  oral  dosage.  It  is  somewhat  irritating  and  upon  this  account  it  may  be 
advisable  to  substitute  sodium  dimethyl  arsenate  (sodium  cacodylate)  ^ 
to  I  grain  (0.022  to  0.065)  or  disodium  methyl  arsenate  (arrhenal)  f  to  ij 
grains  (0.048  to  o.i).  Both  these  are  easily  soluble  in  water  and  may  also 
be  given  by  mouth.  They  are  said  to  be  less  disturbing  to  the  digestive  tract 
than  the  older  preparations.  Arsenic  may  also  be  administered  rectally 
in  the  form  of  Fowler's  solution  or,  if  preferred,  one  of  the  salts  just  men- 
tioned may  be  so  employed,  the  dosage  being  about  twice  that  advised  for 
oral  use. 

Iron  may  be  combined  with  the  arsenic  in  certain  instances  in  which  the 
latter  drug  alone  seems  insufficient.  Wlien  this  is  the  case  the  iron  may  be 
prescribed  as  suggested  under  the  treatment  of  chlorosis. 

Late  in  the  disease  inhalations  of  oxygen  have  been  advised  and  may  be 
beneficial.  If  the  patient  desires  it  a  systematic  treatment  by  means  of  oxygen 
inhalations  may  be  begun  in  the  early  stages. 

The  diminution  in  the  quantity  of  the  circulating  blood  which  is  likely  to 
take  place  near  the  termination  of  the  affection  should  be  combated  by 
giving  hot  normal  salt  solution  by  enteroclysis,  hypodermatoclysis  or  even 
by  intravenous  infusion. 

The  use  of  bone-marrow  has  been  suggested  and  has  seemed  beneficial  in 
certain  instances,  while  in  others  it  has  had  no  effect.  It  may  be  given  fresh 
or  as  the  glycerin  extract  in  quantities  of  an  ounce  to  two  ounces  (30.0  to  60.0) 
daily. 

The  frequently  associated  gastro-intestinal  disturbances,  which  resvilt  from 


LEUC^MIA.  511 

irritation  of  the  stomach,  or  intestinal  fermentation  should  receive  appropriate 
treatment  in  the  form  of  gastric  lavage  or  the  administration  of  intestinal 
antiseptics  such  as  bismuth  naphtholate  or  tetraiodophenolphthaleinate  in 
doses  of  5  grains  (0.33),  phenyl  salicylate,  etc.  The  vegetable  bitters  and 
hydrochloric  acid  are  sometimes  beneficial.  Fortunately  in  pernicious  anaemia 
there  seems  to  be  a  certain  amount  of  tolerance  on  the  part  of  the  stomach 
for  arsenic,  else  gastric  irritation  would  be  more  frequently  observed. 

On  the  ground  that  general  septic  infection  is  likely  to  occur  during  the 
course  of  the  disease  the  use  of  antistreptococcus  serum  has  been  advised. 

When  there  is  evidence  that  the  presence  of  intestinal  parasites  is  respon- 
sible for  the  affection,  anthelmintics  should  be  administered  (see  the  section 
on  intestinal  parasites). 

After  the  more  marked  manifestations  of  the  disease  have  subsided,  that 
is  to  say  during  the  convalescent  period,  iron  should  be  prescribed.  The 
first  sign  of  any  recurrence  is  a  signal  for  the  renewal  of  the  administration 
of  arsenic. 

LEUC^MIA. 

Synonym.     Leucocythaemia, 

Definition.  A  disease  of  the  blood  characterized  by  a  considerable  and 
persistent  increase  in  the  number  of  the  white  corpuscles  and  changes  in  the 
spleen,  lymphatic  glands  and  bone-marrow,  one  or  all. 

Two  distinct  forms,  which  in  many  instances,  however,  are  so  varied  or 
combined  that  definite  separation  becomes  impossible,  are  described:  a, 
Spleno-medullary    or    myelogenous    leuccemia    and    b,  Lymphatic  leuccsmia. 

Etiology.  The  disease  is  common  to  all  countries  and,  while  it  may  occur 
at  any  age  and  in  both  sexes,  is  more  frequent  in  males  during  middle  life. 
Heredity  has  some  influence  in  its  incidence,  a  leucaemic  mother  may,  however, 
bear  healthy  children.  The  affection  has  followed  splenic  traumatism,  and 
syphilis  has  been  considered  in  its  causation  but  these  probably  have  little 
to  do  with  its  aetiology.  Leucaemia  has  been  noted  in  malarial  patients  but 
it  is  by  no  means  certain  that  the  circumstance  has  been  more  than  adventi- 
tious. It  may  develop  dm-ing  pregnancy  or  at  menopause.  Unsanitary 
conditions  of  life  may  be  considered  as  predisposing  factors. 

The  definite  causation  of  leucaemia  is  unknown  although  the  possibility 
of  its  microbic  origin  has  been  seriously  considered,  and  it  has  been  held  to 
be  the  result  of  the  absorption  of  toxic  substances  from  the  digestive  tract 
which  bring  about  a  disordered  action  of  the  blood-making  organs. 

Pathology,  The  body  is  usually  emaciated,  often  extremely  so,  subcuta- 
neous oedema  and  transudates  into  the  serous  cavities  may  be  observed.  The 
large  veins  and  the  heart  contain  greenish-yellow  or  whitish  coagula  which 


512  DISEASES    OF    THE    BLOOD. 

look  like  pus.  Fatty  degeneration  of  the  myocardium  and  pericardial  and 
endocardial  ecchymoses  may  be  present. 

In  spleno-medullary  leuccemia  there  is  marked  splenic  enlargement,  the  organ 
sometimes  weighing  as  much  as  i8  lbs.  (9  kg.).  It  is  often  adherent  to  adja- 
cent structures  and  its  capsule  may  be  thickened.  It  resists  the  knife  but  on 
section  is  brownish  or  mottled  by  lymphoid  tumors  of  grayish  or  yellowish 
tinge  or  by  yellowish-brown  haemorrhagic  infarcts.  The  outline  of  the  Mal- 
pighian  bodies  is  usually  not  distinct.  Under  the  microscope  the  condition 
proves  to  be  one  of  hyperplasia  and  areas  of  fatty  degeneration  and  of 
increased  connective  tissue  may  be  apparent. 

There  is  also  hyperplasia  of  the  red  marrow  which,  instead  of  being  fatty, 
is  yellowish-green  in  color  and  resembles  pus  or  is  dark  brown;  infarcts  may 
be  present  and  the  bone  itself  may  be  enlarged.  The  microscope  reveals 
the  presence  of  many  lymphoid  and  nucleated  red  blood  cells  in  the  marrow 
substance.  Many  polynuclear  leucocytes  are  to  be  seen  and  small  mono- 
nuclear white  cells  are  also  present  but  in  smaller  number. 

Some  enlargement  of  the  lymph  glands  is  usually  noted. 

Lymphatic  leuccemia  is  characterized  by  general  hyperplasia  of  the  lym- 
phatic glands  usually  associated  with  some  splenic  hypertrophy.  The  enlarged 
glands  are  soft  and  movable  and  reddish-gray  in  color.  Lymphatic  tissue 
throughout  the  body,  as  the  tonsils,  the  buccal,  lingual  and  pharyngeal  lymph 
follicles  and  the  solitary  and  agminated  glands  of  the  intestine,  may  take 
part  in  the  hyperplastic  process.  Rarely  is  the  thymus  affected.  Lymphoid 
tissue  may  replace  the  bone-marrow. 

The  liver  is  usually  enlarged  and  with  the  kidneys  may  be  the  seat  of  lym- 
phatic infiltration  and  at  times  may  contain  distinct  lymphatic  growths  which 
also  have  been  found  in  the  stomach,  omentum  and  even  in  the  skin.  Car- 
diac and  pulmonary  changes  do  not  occur. 

Symptoms.  The  onset  of  the  disease  is  gradual  with  pallor,  palpitation, 
dyspnoea,  progressive  weakness,  digestive  disturbances  and  abdominal 
or  glandular  enlargement.  Epistaxes  or  haematemeses  may  be  amongst  the 
early  symptoms  and  have  proved  fatal  in  a  few  instances  almost  before  the 
patient's  true  condition  had  been  suspected. 

Spleno-mediillary  or  myelogenous  leuccemia  is  the  more  common  type  of 
the  disease  and,  as  its  name  indicates,  is  characterized  particularly  by  splenic 
enlargement.  The  increase  in  size  is  gradual  and  pain  and  tenderness  over 
the  organ  may  be  present.  The  enlarged  spleen  is  usually  palpable  below 
the  costal  margin  and  when  extraordinary  increase  in  size  is  present  the 
organ  may  extend  to  the  left  as  far  as  the  umbilicus  and  downward  to  the 
pubes.  Its  edge  is  easily  made  out  and  the  splenic  notch  may  be  readily 
felt.  The  size  may  vary  from  time  to  time  becoming  smaller  after  haemor- 
rhage or  -diarrhoea  and  larger  after  a  full  meal.     Slight  degrees  of  enlarge- 


LEUC^MIA.  513 

ment  may  be  detected  by  percussion,  the  normal  splenic  dulness  being  limited 
by  Luschka's  lines  which  are  drawn  from  the  posterior  superior  iliac  spine  to 
the  nipple  and  from  the  umbilicus  tangent  to  the  lower  margin  of  the  eleventh 
rib.  The  former  is  directly  in  the  short  axis  of  the  organ,  the  latter  in  its  long 
axis.  Palpation  of  the  organ  may  reveal  pulsation  and  a  creaking  fremitus 
and,  upon  auscultation  over  it,  a  murmvir  may  be  audible.  The  aorta  may 
be  prominent  in  the  supra-sternal  notch  (Jaccoud's  sign). 

The  heart  may  be  displaced  upward  by  the  splenic  tumor.  The  pulse 
is  likely  to  be  rapid,  soft  and  full.  Oedema,  locaHzed  in  the  lower  limbs 
or  general,  may  occur  in  the  later  stages  of  the  disease.  Haemorrhages,  espe- 
cially epistaxes,  are  frequent.  Subcutaneous  extravasations  of  blood,  haema- 
temeses,  bleeding  from  the  gums,  into  the  retina,  the  meninges  or  into  the 
serous  cavities  may  be  observed.  Haemorrhages  from  the  bowel  and  diarrhoea 
sometimes  take  place.  Ascites  due  to  venous  obstruction  by  the  pressure 
of  the  splenic  tumor  is  not  uncommon  and  digestive  symptoms,  especially 
nausea  and  vomiting,  are  often  noted.  Gangrenous  processes  with  fever  of 
septic  type  are  serious  manifestations.     Priapism  is  not  infrequent. 

Dyspnoea,  headaches,  vertigo  and  a  tendency  to  faintness  occur  as  a  result 
of  the  anaemia.  Deafness  sometimes  is  present  and  symptoms  resembling 
those  of  Meniere's  disease  may  appear,  due  to  involvement  of  the  semi-circular 
canals.  Haemorrhagic  retinitis  and  changes  due  to  leucasmic  growths  in  the 
retina  may  be  observed.  An  irregular  febrile  movement  is  common.  The 
urine  is  not  characteristic  but  usually  contains  an  increased  amount  of  uric 
acid. 

The  blood  shows  certain  changes  common  to  all  types  of  the  disease;  its 
color  may  be  very  pale.  Upon  coagulation,  when  the  white  cells  are  much  in- 
creased in  number,  the  blood  separates  into  two  layers  one  containing  chiefly 
leucocytes,  the  other  the  red  corpuscles.  The  specific  gravity  is  usually  low 
and  Charcot's  crystals  appear  when  the  blood  is  allowed  to  stand  for  a  time. 

The  changes  characteristic  of  spleno-medullary  leuccBmia  are  as  follows: 

The  red  cells  may  be  nearly  normal  in  number  or  greatly  reduced — even 
below  1,000,000.  The  haemoglobin  is  reduced  out  of  proportion  to  the  dim- 
inution of  the  number  of  red  cells,  there  are  some  poikilocytes  and  nucleated 
red  cells;  in  less  frequent  instances  the  hemoglobin  index  is  high  and  many 
megalocytes  and  megaloblasts  are  present.  The  white  cells  are  greatly  in- 
creased in  number  except  in  the  mildest  types  of  the  affection,  the  average 
being  100,000  to  200,000  in  the  early  stages  to  over  1,000,000  late  in  the 
disease.  Under  the  administration  of  arsenic  or  during  remissions  the  number 
may  fall  to  normal  but  myelocytes  are  almost  invariably  present.  The  nor- 
mal amoeboid  movement  of  the  polynuclear  cells  is  diminished  and  the  mye- 
locytes may  be  slightly  motile.  There  is  a  constant  increase  in  the  polynuclear 
neutrophiles  and  these  may  number  200,000  or  more.     Their  size  is  much 

Z3 


514  DISEASES    OF    THE    BLOOD. 

more  variable  than  in  normal  blood,  their  neutrophile  granules  may  be  absent 
or  scarce.  The  polynuclear  eosinophiles  are  also  increased  but  are  not  changed 
in  character  and  the  large  mononuclear  cells  are  often  increased  as  well. 
Cells  with  basophilic  granules  and  polymorphous  nuclei  are  frequently  present 
in  considerable  number.  The  large  and  small  lymphocytes  remain  normal 
or  undergo  moderate  increase  in  number. 

The  myelocytes  are  characteristic  and  pathognomonic.  These  are  not 
present  in  normal  blood;  they  are  large  mononuclear  cells  and  occur  in  three 
forms,  neutrophilic,  eosinophilic  and  basophilic,  the  first  being  most  abundant 
and  the  last  least  common  of  the  three.  The  neutrophilic  forms  have  a  large 
oval  nucleus  and  contain  a  varying  quantity  of  neutrophilic  granules.  At 
times  they  are  very  large  and  in  advanced  instances  of  the  disease  degenerated 
forms  are  frequent.  The  eosinophilic  myelocytes  are  fairly  characteristic 
of  leucaemia  but  may  not  be  present  in  large  numbers.  The  basophiles 
resemble  the  eosinophilic  myelocytes  but  are  fewer  in  number. 

The  myelocytes  are  found  in  great  numbers  in  the  spleen,  lymph  glands 
and  liver.  During  acute  infections,  occurring  in  the  course  of  leucaemia,  they 
may  be  greatly  reduced  in  number  in  the  circulation  or  even  wholly  disappear 
and,  if  the  infective  process  is  long  continued,  their  number  in  the  organs  is 
also  decreased  as  is  evidenced  by  a  reduction  in  the  splenic  and  hepatic  enlarge- 
ments. Similar  diminutions  may  occur  after  the  administration  of  arsenic 
and  just  before  death. 

Lymphatic  leucamia  is  more  rare  than  the  preceding  type  of  the  disease 
and  is  prone  to  occiu".  in  an  acute  and  rapidly  fatal  form.  It  occurs  more 
often  in  the  young  and  is  characterized  more  particularly  by  enlargement  in 
the  superficial  lymphatic  glands.  The  tumors  remain  soft,  movable  and 
elastic. 

The  disease  in  its  more  acute  type  may  resemble  enteric  fever,  sepsis  or 
scurvy.  The  febrile  movement  is  moderate,  the  anaemia  rapidly  increases, 
haemorrhages  take  place  and  the  spleen  and  liver  are  only  moderately  enlarged. 
Lymphatic  deposits  in  the  skin  may  occtir. 

The  Blood.  In  the  more  acute  instances  there  is  rapid  diminution  of  the 
red  cells  to  2,000,000  or  less  and  normoblasts  and  megaloblasts  may  be  found, 
the  latter  rarely.  The  leucocytes  are  increased  but  much  less  so  than  in 
spleno-myelogenous  leucaemia.  Myelocytes  are  seldom  present  but  may  be 
seen  in  small  number.  The  increase  in  the  number  of  leucocytes  affects 
chiefly  the  large  and  small  lymphocytes;  there  is  relative  diminution  of  the 
eosinophiles  and  varying  numbers  of  polynuclear  and  large  mononuclear 
c^Us  are  observed.  The  characteristic  change  is  the  presence  of  large  lym- 
phocytes. In  these,  at  times,  degeneration  both  of  cell  body  and  nucleus 
is  seen.  The  appearance  of  acute  intercurrent  disease  reduces  the  leucocytosis, 
causing  at  the  same  time  a  relative  increase  in  the  polynuclear  neutrophiles. 


LEUC^MIA.  515 

Protracted  infections  may  cause  a  disappearance  of  the  lesions  in  the  marrow 
and  of  the  cutaneous  lymphatic  growths. 

The  haemoglobin  is  diminished  in  close  proportion  to  the  reduction  in  the 
number  of  red  corpuscles. 

In  chronic  lymphatic  leucamia  the  blood  changes  are  somewhat  different. 
Usually  there  is  less  diminution  of  the  red  cells,  the  nucleated  reds  are  fewer 
and  are  mostly  normoblasts;  crises  of  normoblasts  may  occur.  The  average 
leucocytosis  is  about  100,000  but  a  count  of  four  or  five  times  this  number  is 
not  rare.  The  increase  in  the  number  of  leucocytes  chiefly  affects  the  small 
lymphoc}'tes.  A  small  number  of  eosinophils,  neutrophils  and  myelocytes 
may  be  present.  Variations  in  the  leucocytosis  are  common  and  during  inter- 
current febrile  disease  the  leucocytosis  may  fall  temporarily  to  normal.  The 
hsemoglobin  index  is  low. 

The  diagnosis  cannot  be  accurately  made  without  examination  of  the 
blood,  but  the  microscopical  study  of  this  fluid  together  with  a  differential 
counting  of  the  leucocytes  will  separate  the  disease  from  pseudo-leucEemia 
and  the  various  anaemias  whose  clinical  resemblance  to  leucaemia  may  be 
extremely  close. 

The  prognosis  is  generally  unfavorable  but  remissions  of  the  progress 
of  the  affection  are  not  infrequent  and  a  few  instances  of  apparent  cure  have 
been  reported;  death,  however,  usually  takes  place  within  about  tliree  years  and 
often  in  less  time;  the  patients  who  have  frequent  haemorrhages,  a  marked 
febrile  movement  and  anasarca  are  likely  to  do  badly. 

Treatment.  The  diet  and  hygiene  of  this  disease  are  identical  with  that 
of  pernicious  anaemia,  and  rest  in  bed  is  quite  as  important  a  factor  in  the 
management  of  leucaemia  as  in  that  of  the  previously  considered  affection. 
The  administration  of  arsenic  in  the  manner  suggested  for  pernicious  anaemia 
often  is  beneficial  and  should  not  be  neglected.  Iron  is  also  useful  and 
inhalations  of  oxygen  are  said  to  exert  a  curative  effect.  They  should  be 
employed  daily  and  in  amount  varying  from  5  to  12  gallons  (20  to  50  litres). 
Bone-marrow  may  be  given  either  fresh  or  as  the  glycerin  extract  in  quantities 
of  I  to  2  ounces  (30.0  to  60.0)  daily  but  is  hardly  likely  to  influence  the  progress 
of  the  disease  materially. 

Recent  remarkable  results  have  been  achieved  with  the  Rontgen  ray. 
The  reason  for  its  beneficent  action  is  not  well  understood  but  under  its 
influence  there  is  a  diminution  of  the  number  of  the  leucocytes  in  the  blood 
as  weU  as  of  the  size  of  the  spleen.  It  is  probable  that  the  ray  determines 
an  autolysis,  analogous  to  that  which  occurs  after  pneumonia  and  as  a  result 
of  which  the  exudate  of  the  disease  is  absorbed,  and  that  the  end-products 
of  the  excessive  number  of  white  cells  are  excreted  through  the  urine,  causing 
an  increase  in  the  uric  acid,  phosphates  and  purin  bodies  which  this  fluid 
contains.     Certain  it  is,  at  any  rate,  that  improvement  of  leucaemic  patients 


5i6  DISEASES   OF    THE    BLOOD. 

is  evidenced  by  an  increased  uric  acid,  phosphate  and  purin  excretion  in  the 
urine.  Cures  have  been  reported  in  instances  of  spleno-myelogenous  leu- 
caemia but  the  X-ray  seems  to  be  less  efi&cient  in  the  lymphatic  type  of  the 
affection.  With  the  diminution  in  the  splenic  tumor  and  in  the  leucocytosis 
it  is  stated  that  the  red  cells  and  their  haemoglobin  content  are  increased,  the 
glandular  swellings  become  smaller  and  that  the  general  condition  becomes 
in  every  way  improved.  The  technique  of  the  treatment  consists  in  applying 
the  light  over  the  spleen,  the  enlarged  glands,  the  chest,  knees  and  elbows. 
The  tube  must  be  so  excited  as  to  give  a  light  penetrating  enough  to  reach 
the  diseased  organs,  A  relatively  hard  tube  should  be  used;  the  low  vacuum 
tube,  which  expends  its  energy  upon  but  does  not  penetrate  the  skin,  is  to  be 
avoided,  this  being  the  type  of  tube  which  produces  biirns.  It  is  important 
that  the  genitals  should  always  be  protected  by  an  impenetrable  screen  lest 
sterility  be  caused.  In  summing  up  this  treatment  of  leucaemia  it  may  be 
said  that  at  present  too  few  results  have  been  reported  to  form  any  absolute 
conclusions  as  to  its  efl&cacy;  it  should,  however,  be  employed  in  all  instances, 
for  while  recovery  may  not  be  brought  about,  benefit  is  usually  achieved. 

The  surgical  treatment  of  leucaemia  by  means  of  splenectomy  has  been 
suggested  but  it  offers  no  very  definite  hope  of  cure. 

LEUCAN^MIA. 

This  term  has  been  applied  by  von  Leube  to  conditions  which  exhibit  a 
combination  of  the  features  of  marked  anaemia  and  leucaemia.  The  affection 
is  usually  acute  in  onset  and  in  course,  is  apparently  an  infective  process 
and  frequently  begins  with  an  inflammation  of  the  tonsils.  It  is  characterized 
by  prostration,  fever,  marked  pallor,  haemorrhages  and  splenic  and  hepatic 
enlargement;  glandular  tumors  may  be  present.  The  red  cells  are  greatly 
diminished  and  there  may  be  numerous  normoblasts  and  megaloblasts;  the 
haemoglobin  percentage  is  relatively  high.  The  leucocytes  may  not  be  greatly 
increased  in  number  but  there  is  usually  relative  increase  in  the  number  of 
lymphocytes. 

The  condition  is  usually  fatal  in  from  one  week  to  two  or  three  months. 

Other  observers  have  reported  leucanaemic  states  which  resemble  on  the 
one  hand  acute  myelogenous  leucaemia  and  on  the  other  an  acute  infectious 
disease. 

CHLOROMA. 

This  is  a  condition  apparently  allied  to  leucaemia,  characterized  by  the 
development  of  greenish  color  in  the  periosteum  and  marrow  of  the  cranial 
bones  especially  in  those  about  the  orbit.  Metastatic  growths  may  appear  in 
the  organs.     Lymphoid  infiltration  of  the  conjunctiva  and  cornea  may  occur. 


ANEMIA    INFANTUM.  517 

The  disease  may  be  classed  as  related  to  lymphosarcoma  as  well  as  to  leu- 
caemia and  is  believed  to  consist  in  a  neoplastic  hyperplasia  of  the  parent 
cells  of  the  leucocytes  which  develops  in  the  red  marrow,  the  periosteum  being 
secondarily  affected. 

The  sjrmptoms  consist  of  orbital  pain,  exophthalmos,  deafness,  epistaxis 
and  subconjunctival  haemorrhage.  There  is  progressive  weakness  with 
pallor,  anaemia  and  leucocytosis,  the  latter  not  being  essential.  Resilient 
tumors  appear  in  the  orbital,  temporal  and  parotid  regions  and  there  may  be 
paralyses  due  to  pressure  exerted  upon  the  nerve  trunks  by  tumors  growing 
from  the  spinal  periosteum.  The  evolution  of  the  disease  is  rapid  and  its 
termination  fatal. 

CHRONIC  CYANOSIS.    (VAQUEZ'S  DISEASE.) 

Definition.  A  rare  condition  characterized  by  chronic  cyanosis  of  the 
skin,  polycythaemia  and  splenic  enlargement. 

The  causation  of  the  disease  is  unknown  but  the  affection  is  evidently 
distinct  from  the  polycythsemia  which  occurs  with  tuberculosis  of  the  spleen, 
in  congenital  heart  disease  and  in  subjects  who  have  lived  at  a  high  altitude. 
The  most  typical  symptom  is  the  cyanosis  which  is  usually  associated  with 
an  enlarged  spleen.  Accompanying  symptoms  are  weakness,  prostration 
and  headache  with  vertigo,  abdominal  and  dorsal  pain  in  certain  instances; 
albuminuria  and  digestive  disturbances  may  be  present.  There  is  no  fever 
nor  vascular  hypertension. 

The  blood  is  dark  in  color  and  its  viscosity  is  increased;  the  specific  gravity 
may  reach  1,083  and  the  haemoglobin  percentage  even  as  high  as  200.  The 
red  blood  cells  are  markedly  increased  in  number  and  may  be  even  as  many 
as  13,000,000  per  cubic  millimeter.  There  is  usually  no  extreme  leucocytosis, 
the  average  number  of  white  cells  being  below  10,000  although  a  number  as 
high  as  30,000  has  been  observed.  Fatal  instances  of  the  affection  have 
been  noted. 

ANAEMIA  INFANTUM. 

Synonym.    Anaemia  Infantum  Pseudo-leucaemica. 

Definition.  A  disease  of  childhood  which  resembles  leucaemia  but  in  which 
the  leucocytosis  is  less  marked,  there  are  no  lymphomatous  tumors  and  from 
which  recovery  may  take  place. 

.etiology.  The  causation  of  the  affection  is  unknown  but  rickets,  syphilis 
and  digestive  disorders  may  be  contributing  factors.  The  condition  is  very 
rare  but  may  occur  in  children  between  the  ages  of  i  and  7  years. 

Pathology.  The  most  characteristic  lesion  is  a  considerable  splenic  enlarge- 
ment of  simple  hyperplastic  type.     The  liver  may  be  enlarged  and  the  lymph 


5l8  DISEASES    OF    THE    BLOOD. 

glands  may  be  increased  in  size.  The  marrow  may  be  redder  than  normal, 
there  are  never  any  lymphomatous  growths. 

Symptoms.  The  onset  is  gradual  with  increasing  pallor  although  a  corre- 
sponding emaciation  may  not  take  place.  The  spleen  is  palpably  enlarged 
and  may  vary  in  size  from  time  to  time.  Hepatic  enlargement  may  or  may  not 
be  present,  the  same  is  true  of  glandvilar  swellings.  Digestive  disturbances 
are  frequent.  The  course  of  the  affection  is  chronic  and  protracted;  recovery 
with  gradual  amelioration  of  all  the  symptoms  and  a  return  of  the  blood  to 
normal  may  occur. 

The  Blood.  The  specific  gravity  is  diminished.  There  is  marked  dimi- 
nution in  the  number  of  red  cells  (2,000,000  or  even  fewer)  and  there  are 
changes  in  size  and  shape;  nucleated  cells  of  normal  size  may  be  numerous 
and  in  the  severer  instances  of  the  disease  megaloblasts  may  be  observed  in 
considerable  number.  The  leucocytosis  may  reach  100,000  but  is  usually 
from  20,000  to  50,000,  varying  upon  occasions.  While  the  normal  propor- 
tions of  the  different  types  of  white  cells  are  said  to  persist  the  mono-  or  poly- 
nuclear  forms  may  be  relatively  increased.     Myelocytes  are  rarely  seen. 

The  diagnosis  may  be  made  upon  the  presence  of  syphilis  or  rickets  with 
digestive  disorders,  enlarged. spleen,  anaemia  with  leucocytosis  and  the  absence 
of  myelocytes  from  the  blood  and  of  haemorrhages  and  lymphomatous  tumors. 

The  prognosis  should  be  guarded.  Recovery  from  the  condition  itself 
may  take  place  but  intercurrent  affections  often  result  fatally. 

Treatment.  If  syphilis,  rickets  or  gastro-intestinal  derangements  are 
present  they  should  receive  appropriate  treatment.  The  management  of 
the  disease  itself  should  be  conducted  as  in  leucaemia  or  severe  anaemia.  The 
Rontgen  rays  should  be  used  with  caution  in  children. 

PURPURA 

Synonyms.    Morbus  Maculosus;  Peliosis. 

Definition.  The  term  purpura  is  applied  to  a  number  of  dyscrasiae  which 
are  characterized  by  extravasations  of  blood  beneath  the  skin  or  mucous  mem- 
branes. These  haemorrhages  vary  greatly  in  extent ;  when  of  minute  size  they 
are  termed  petechiae,  when  larger,  ecchymoses;  they  do  not  disappear  on 
pressure;  when  fresh  they  are  of  bright  red  color,  later  becoming  brownish, 
Associated  with  the  tendency  to  purpuric  haemorrhages  there  is  a  diminished 
disposition  upon  the  part  of  the  blood  to  coagulate. 

While  it  is  difl&cult  to  separate  the  different  types  of  purpura,  the  following 
classification  is  the  one  usually  given: 

Symptomatic  purpura  comprises  those  types  of  the  affection  which  occiu" 
in  association  with  and  as  a  part  of  the  symptom  complex  of  various  diseases 
and  conditions. 


PURPURA.  519 

a.  The  severer  forms  of  the  infectious  diseases  often  exhibit  a  purpuric 
rash  and  ecchymoses  are  not  infrequent  in  septic  and  pyaemic  conditions; 
they  are  very  common  in  infectious  endocarditis  and  in  epidemic  cerebro- 
spinal meningitis. 

h.  The  presence  of  various  poisons  in  the  blood — snake  venom,  over- 
doses of  various  drugs  such  as  merciiry,  ergot,  potassium  iodide,  quinine, 
etc. — is  sometimes  evidenced  by  purpuric  spots.  Certain  subjects  who  possess 
idiosyncrasies  may  exhibit  the  haemorrhages  after  the  administration  of 
physiological  doses  of  these  substances. 

c.  In  the  cachexia  of  such  clironic  diseases  as  carcinoma,  nephritis,  tuber- 
culosis, pseudo-leucaemia,  etc.,  purpuric  extravasations  are  often  observed. 

d.  Nervous  affections,  both  organic,  such  as  tabes  dorsalis,  myelitis  and 
neuralgia,  and  functional — as  in  hysteria — may  be  accompanied  by  a  symp- 
tomatic purpura. 

e.  Mechanically  produced  ecchymoses  may  appear  in  any  condition  in  which 
circulation  is  impeded,  such  as  a  paroxysm  in  whooping  cough  or  epilepsy. 

/.  Senile  purpura;  in  aged  individuals  it  is  not  unusual  to  note  subcutan- 
eous haemorrhagic  extravasations,  especially  upon  the  extremities. 

Arthritic  Purpura. 

In  this  form  of  the  affection  joint  lesions  are  the  characteristic  feature. 

Arthritic  purpura  may  be  separated  into  three  varieties: 

a.  Simple  arthritic  purpura  or  purpura  simplex  occurring  usually  in  children; 
this  is  a  mild  affection  and  is  characterized  by  pain  about  the  joints,  slight  febrile 
movement  and  sometimes  by  digestive  disorders  and  diarrhoea.  The  patient 
may  lose  some  flesh  and  become  somewhat  anaemic.  Ecchymoses  are  present 
upon  the  limbs,  chiefly  about  the  knees,  but  they  may  be  observed  upon  the 
arms  and  body.     Recovery  within  ten  days  generally  takes  place. 

h.  Peliosis  rheumatica  or  Schonlein's  disease  is  a  more  serious  condition. 
It  is  most  common  in  young  adult  males  and  is  characterized  by  multiple 
joint  involvement.  The  articulations  are  swollen,  tender  and  painful  and 
there  is  a  rise  of  temperature,  as  high  as  103°  F.  (39.4°  C.)  in  some  instances. 
Pharyngitis  may  be  an  initial  symptom.  The  rash  appears  first  about  the 
affected  joints  and  may  be  purpuric  or  urticarial.  Nodes  similar  to  those  of 
erythema  nodosum  may  be  noted.  Vesicles  {pemphigoid  purpura)  may  be 
present  and  necrosis  with  sloughing  of  the  skin  and  even  of  the  soft  palate 
may  take  place.  There  may  be,  in  severe  types  of  the  affection,  albuminuria 
and  even  haematuria;  endocarditis  and  pericarditis  are  rare  complications. 
Recovery  is  the  rule  but  relapses  and  recurrences  are  not  uncommon. 

c.  Henoch^s  purpura  or  purpura  with  visceral  lesions  is  seen  particularly 
in  children  but  may  occur  in  adults  and,  while  it  is  associated  with  various 


520  DISEASES    OF    THE    BLOOD. 

cutaneous  lesions  such  as  ecchymoses,  urticaria,  angioneurotic  oedema  or 
different  types  of  erythema,  its  more  especial  characteristic  is  a  gastro-intes- 
tinal  disturbance  evidenced  by  colic,  nausea,  vomiting  and  diarrhoea;  joint 
involvement  is  often  present  and  the  same  is  true  of  splenic  enlargement. 
Nephritis  is  a  severe  complication  and  may  cause  death.  The  gastro-enteric 
and  renal  manifestations  are  probably  the  result  of  the  occurrence  of  lesions 
of  the  digestive  tract  and  kidneys  analogous  to  those  of  the  skin. 

Purpura  Haemorrhagica. 

Synonym.     Morbus  Maculosus  Werlhofii. 

This  variety  of  purpvura  is  most  often  seen  in  debilitated  subjects,  partic- 
ularly young  girls,  although  healthy  adults  may  be  attacked.  The  con- 
dition is  characterized  by  the  occurrence  of  haemorrhages  from  the  mucous 
membranes  of  the  nose,  mouth  and  gastro-intestinal  tract  as  well  as  into  the 
skin.  The  haemorrhages  may  be  severe,  the  cutaneous  ecchymoses  rapidly 
increase  in  size  and  marked  anaemia  quickly  results.  There  is  usually  a 
moderate  febrile  movement.  The  onset  is  usually  preceded  by  a  few  days 
of  malaise  and  weakness. 

Death  may  take  place  from  loss  of  blood  or  as  a  result  of  haemorrhage  into 
the  brain.  In  the  instances  which  recover  the  affection  usually  lasts  two  or 
three  weeks. 

Purpura  julminans  occurs  chiefly  in  children  and  is  rapidly  fatal,  there 
being  extravasations  into  the  skin  of  large  extent,  usually  without  involve- 
ment of  the  mucous  membranes. 

The  diagnosis.  Purpura  haemorrhagica  is  to  be  separated  from  scurvy 
by  the  lack  of  involvement  of  the  gums.  In  the  haemorrhagic  types  of  the 
infectious  diseases  there  is  a  more  marked  rise  of  temperature  with  character- 
istic symptoms. 

The  prognosis  is  usually  favorable  but  in  purpura  fulminans  death  occurs, 
often  within  twenty-four  hours. 

Treatment.  The  tendency  to  purpuric  disease  should  be  combated  by 
the  employment  of  all  possible  means  which  will  build  up  the  patient's  general 
condition.  Of  these  good  food  and  plenty  of  fresh  air  with  proper  exercise 
and  attention  to  the  general  hygiene  are  of  paramount  importance.  A  sojourn 
in  a  warm  climate  is  very  beneficial.  Any  anaemic  manifestations  necessi- 
tate the  administration  of  iron. 

In  the  arthritic  form  of  the  affection  the  salicylates  and  salicylic  acid  may 
be  employed  as  in  acute  articular  rheumatism,  care  being  taken  not  to  disturb 
the  digestion.  In  this  type  of  purpura  as  well  as  in  purpura  simplex  arsenic 
is  indicated  and  should  be  given  in  increasing  doses  up  to  the  limit  of  tolerance; 
irritation  of  the  stomach,  however,  should  be  studiously  avoided. 


HEMORRHAGIC    DISEASES    OF    THE    NEW-BORN.  521 

The  hsemorrhages  and  the  tendency  to  a  diminution  in  the  coagulability 
of  the  blood  may  be  controlled  by  the  administration  of  calcium  lactate  in 
20  grain  (1.33)  doses  three  or  four  times  daily.  The  dosage  for  a  child  should 
be  regulated  in  accordance  with  the  patient's  age.  Calcium  chloride  in 
similar  doses  may  also  be  prescribed  but  is  less  efficient  in  increasing  the 
coagulation  of  the  blood  than  the  lactate.  It  must  be  remembered  that  the 
administration  of  the  calcium  salts  for  more  than  three  or  four  days  at  a  time 
causes  a  diminished  coagidability. 

Of  other  remedies  to  check  the  bleeding,  ergot,  tannic  and  gallic  acids, 
iron  persulphate,  dilute  or  aromatic  sulphuric  acid  may  be  given  in  the  usual 
doses.  Oil  of  turpentine,  15  drops  (i.o)  three  times  a  day,  may  be  effective 
in  some  instances  but  in  the  calcium  salts  we  have  a  means  of  increasing  the 
coagulability  of  the  blood  and  a  method  of  controlling  haemorrhage  which 
is  much  to  be  preferred  to  the  administration  of  astringents  or  vaso-constric- 
tor  drugs.  The  hypodermatic  administration  of  gelatin  solutions  has  been 
suggested  but  is  probably  less  effective  than  the  method  of  treatment  given 
above.  These  solutions  as  well  as  one  of  adrenalin  chloride,  when  used  as 
irrigations,  often  afford  an  excellent  means  of  checking  buccal  and  nasal 
haemorrhages. 

HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

Hemorrhagic  Syphilis  of  the  New-horn.  The  haemorrhages  may  be  con- 
genital or  they  may  appear  within  a  few  days  after  birth.  Bleeding  occurs 
from  the  navel  and  from  the  mucous  membranes  of  the  mouth  and  digestive 
tract.  Haematuria  may  be  observed,  jaundice  may  appear.  There  is  rapid 
emaciation  and  death  usually  follows  within  ten  days.  Post  mortem  examina- 
tion reveals  haemorrhages  and  syphilitic  disease  of  the  viscera  and  other  tissues. 

Epidemic  hcemoglohinuria  or  WtnckeVs  disease  may  occur  epidemically 
in  maternity  hospitals.  A  few  days  after  birth,  usually  the  fourth,  the  skin 
becomes  bluish  and  jaundice  appears,  the  temperature  is  elevated  and  gastro- 
intestinal symptoms  with  rapid  pulse  and  respiration  are  noted.  The  urine 
is  dark  and  contains  albumin,  casts  and  blood  pigment  (methasmoglobin). 
Death  takes  place  in  a  few  days  or  even  within  twelve  hours.  Upon  autopsy 
the  spleen  may  be  found  enlarged  and,  with  the  kidneys,  is  dark  in  color;  the 
liver  and  heart  may  be  the  seat  of  fatty  degeneration.  Minute  hagmorrhages 
may  be  present  in  the  viscera.     There  is  no  sepsis  of  the  umbilical  vessels. 

Acute  degeneration  of  the  viscera  in  the  new-born  or  BuhVs  disease 
differs  from  the  condition  just  described  in  that  fatty  degeneration  of  the  organs 
is  a  constant  lesion. 

Morbus  maculosus  neonatorum  is  a  condition  characterized  by  haemorrhages 
from  various  tissues,  particularly  those  of  the  digestive  tract.     The  bleeding 


522  DISEASES    OF    THE    BLOOD. 

usually  appears  during  the  first  week  of  life  but  may  be  delayed  to  the  sec- 
ond or  third. 

The  haemorrhage  most  commonly  is  from  the  intestine  (inelana  neonato- 
rum) but  may  come  from  the  nose,  mouth,  stomach  or  umbilicus.  Haema- 
togenous  jaundice  may  be  associated  and  there  may  be  a  febrile  movement. 
Post  mortem  lesions  such  as  are  found  in  epidemic  haemoglobinuria  do  not 
occur  but  ulcerations  of  the  digestive  tract  may  be  demonstrated.  Death 
usually  takes  place  within  a  week. 

Treatment  is  usually  unavailing  but  recoveries  have  been  reported.  The 
patient  should  be  kept  entirely  at  rest  with  the  head  low.  The  child  should 
not  be  lifted  even  to  be  fed,  this  process  being  best  carried  on  by  means  of  a 
teaspoon  or  minim  dropper,  the  mother's  milk  being  employed.  Warmth 
is  absolutely  necessary  and  the  best  means  for  providing  an  even  warm  tem- 
perature is  the  incubator.  If  this  appliance  is  unavailable  the  child's  couch 
may  be  suspended  over  hot  water  bags,  heated  bricks  or  fiat  irons.  The 
proper  temperature  is  about  go°  F.  (32.°  C).  Stimulation  by  means  of  the 
hypodermatic  administration  of  small  quantities  of  whiskey  is  often  indicated. 
The  umbilical  haemorrhage  may  be  controlled  by  the  application  of  a  pad 
of  sterile  gauze  held  in  place  by  means  of  strips  of  adhesive  plaster.  Bleeding 
points  which  can  be  reached  should  be  touched  with  stick  silver  nitrate  or 
chromic  acid.  Nasal  and  mouth  washes  of  adrenalin  chloride  solution  may 
be  employed  and  suprarenal  extract  in  doses  of  i  to  2  grains  (0.065  to  0.13) 
every  two  hours  may  be  given  internally:  i  to  ij  ounces  (30.0  to  45.0)  of 
a  sterilized  2  percent,  gelatin  solution  may  be  given  hypodermatically 
two  or  three  times  daily  and  are  said  to  be  beneficial.  Gallic  acid — i  grain 
(0.065) — '^^y  be  given  by  the  mouth  and  ergotine — i  grain(o.o65) — may  be 
given  under  the  skin  three  times  daily.  Astringent  injections  are  usually  useless 
in  the  control  of  the  haemorrhages  from  the  bowels  for  the  bleeding,  in  most 
instances,  is  from  lesions  too  far  up  in  the  digestive  tract  to  be  reached,  but 
a  half  ounce  (15.0)  of  a  5  to  10  percent,  aqueous  solution  of  calcium  lactate 
or  chloride  may  be  given  by  the  rectum  in  the  hope  that  by  its  absorption 
the  coagulability  of  the  blood  may  be  increased.  These  substances  may 
also  be  given  by  mouth  in  small  doses — i  to  2  grains  (0.065  ^^  °-i3) — with  the 
same  purpose  in  view.  It  must  be  remembered,  however,  that  drugs  should 
be  given  orally  with  the  greatest  care. 

HEMOPHILIA. 

Definition.  A  constitutional  dyscrasia,  usually  hereditary,  and  character- 
ized by  a  tendency  to  persistent  haemorrhage,  spontaneous  or  the  result  of 
injury. 

.Etiology.     The  hereditary  tendency  to  haemophilia  has  long  been  recog- 


HAEMOPHILIA.  523 

nized.  In  rare  instances  the  condition  may  be  acquired.  The  hasmor- 
rhagic  diathesis  may  be  transmitted  from  generation  to  generation  and  cer- 
tain families  are  on  record  in  which  the  condition  has  been  present  for  as 
many  as  seven  successive  generations.  The  condition  is  more  common  in  males 
than  in  females  but  is  transmitted  in  most  instances  through  the  mother; 
thus  the  daughter  of  a  bleeder,  although  herself  unaffected,  will  usually  give 
birth  to  progeny  possessing  the  haemophilic  tendency,  although  in  a  large 
family  of  such  children  every  one  may  not  be  a  bleeder. 

Haemophilia  is  said  to  affect  the  Anglo-Saxon  races  much  more  commonly 
than  the  Latin,  instances  have,  however,  been  observed  in  negroes.  In  the 
families  of  bleeders,  which  are  often  large,  the  offspring  have  an  appearance 
of  health,  the  skins  are  usually  soft  and  fine  and  the  coloring  commonly  is 
blond. 

Pathology.  The  only  abnormality  which  is  constantly  found  in  the  blood 
is  a  delayed  coagulation  time.  Sometimes  vascular  changes,  such  as  a  thin- 
ness of  the  walls  of  the  vessels  with  fatty  degeneration  of  the  intima,  are 
observed. 

Symptoms.  The  condition  usually  manifests  itself  in  childhood  before 
the  tenth  year.  It  is  brought  to  notice  by  the  incidence  of  an  obstinate  haemor- 
rhage, often  the  result  of  slight  injury,  such  as  a  small  cut,  the  drawing  of  a 
tooth,  etc.  Umbilical  haemorrhage  may  be  persistent  in  the  new-born  and 
fatalities  have  resulted  from  circumcision.  In  women  menorrhagia  is  the 
rule;  it  is  not,  however,  uncontrollable  nor  is  post-partum  haemorrhage  a 
feature  of  haemophilia.  The  bleeding  may  take  place  from  almost  any  part 
but  epistaxis  is  most  frequent;  it  may  occur  spontaneously  or  be  precipitated 
by  blowing  the  nose.  Interstitial  haemorrhages  are  rare  but  in  bleeders  slight 
blows  suffice  to  produce  ecchymosis.  Subjects  have  been  observed  in  whom 
the  tendency  to  haemorrhage  was  in  the  neck  and  head  only. 

The  bleeding  is  a  slow  capillary  oozing  and  may  continue  for  hours,  even 
resulting  fatally.  When  once  stopped  the  patient's  blood  rapidly  regenerates 
but  frequent  recurrences  result  in  a  secondary  anaemia.  Haematomata 
following  traumatism  are  common. 

Intra-articular  haemorrhages  may  be  observed;  they  usually  involve  the 
larger  joints,  the  affection  being  usually  of  acute  development  and  evidenced  by 
pain,  swelling  and  a  rise  in  temperature.  At  times  there  is  permanent  joint 
deformity  and  the  condition  may  be  mistaken  for  tuberculous  arthritis. 

The  diagnosis  in  the  presence  of  a  family  history  is  simple  but  one  should 
be  guarded  in  attributing  any  single  obstinate  hccmorrhage  to  haemophilia. 
The  diagnosis  is  justifiable  only  in  the  presence  of  successive  hjemorrhages, 
spontaneous  or  otherwise,  which  resist  the  usual  means  of  control.  The 
association  of  arthritic  manifestations  is  distinctly  in  favor  of  haemophilia. 

The  prognosis  is  the  most  unfavorable  in  the  subjects  who  give  evidence 


524 


DISEASES    OF    THE    BLOOD. 


of  the  affection  early  in  life;  the  condition,  has,  however,  been  outgrown  in 
some  instances.  In  the  early  instances  death  usually  takes  place  before  the 
eighth  year.  Haemophilia  is  more  serious  in  boys  than  in  girls  on  account  of 
the  greater  susceptibility  of  the  former  to  injury. 

Treatment.  Prophylaxis  lies  in  the  protection  of  the  haemophilic  subject 
from  injury  and  in  forbidding  the  marriage  of  the  daughters  of  haemophilic 
families.     Surgical  operations  should  be  avoided. 

Haemophilic  subjects  should  regulate  their  lives  in  the  strictest  accordance 
with  the  rules  of  hygiene.  Diet  and  exercise  in  the  fresh  air  are  important 
and  any  anaemic  condition  should  be  combated  by  the  administration  of 
iron,  arsenic  and  other  tonics. 

When  a  haemorrhage  occurs  the  patient  should  be  put  to  bed  and  kept 
absolutely  at  rest  and  calcium  lactate  in  doses  of  20  grains  (1.33)  thrice 
daily  should  be  prescribed.  In  this  substance  we  have  an  active  means  of 
increasing  the  coagulability  of  the  blood  but  its  use  should  not  be  continued 
too  long,  for  after  a  certain  time  it  reaches  its  maximum  effect  and  from  then  the 
coagulability  becomes  lessened.  Calcium  cliloride  may  be  employed  in  the 
same  dosage  but  is  less  satisfactory.  Compresses  should  be  applied  to  the 
site  of  the  haemorrhage;  these  may  be  moistened  with  i  to  1,000  adrenalin 
chloride  solution  or  the  bleeding  siu-face  may  be  powdered  with  dried  supra- 
renal extract.  The  local  application  of  5  or  10  percent,  gelatin  solution  has 
been  suggested  and  the  subcutaneous  injection  of  a  pint  (500.0)  or  more  of 
the  same  has  its  advocates.  Other  local  haemostatics  such  as  tannic  and 
gallic  acids,  hydrogen  dioxide,  solutions  of  iron  perchloride  or  persulphate 
may  be  employed.  In  epistaxis,  before  packing  the  nares,  the  topical  use 
of  adrenalin  chloride  solution  i  to  1,000  and  the  inhalation  of  carbpn  dioxide 
gas  may  be  tried. 

Upon  internal  remedies  other  than  the  calcium  salts  little  dependence  is 
to  be  placed;  ergot  may  be  tried,  tincture  of  ferric  chloride  ^  drachm  (2.0) 
every  two  hours  has  been  recommended  and  ergotine  may  be  given  hypoder- 
matically. 

The  after  treatment  of  the  haemorrhage  consists  in  the  employment  of  the 
means  indicated  in  the  management  of  secondary  anaemia. 


THE    WANDERING    SPLEEN.  525 


CHAPTER  VI. 
DISEASES  OF  THE  DUCTLESS  GLANDS. 

DISEASES  OF  THE  SPLEEN. 

Primary  splenic  disease  is  a  very  rare  condition,  most  of  the  affections 
of  this  organ  being  associated  with  other  morbid  states  and  are  considered 
under  the  discussion  of  the  diseases  to  which  they  are  secondary,  such  as 
malaria,  affections  of  the  blood,  hepatic  and  cardiac  diseases,  etc.  Certain 
splenic  conditions,  however,  remain  which  should  be  described  by  themselves. 

THE  WANDERING  SPLEEN. 

Synonyms.     Floating  Spleen;  Dislocation  of  the  Spleen;  Movable  Spleen. 

This  condition  is  the  result  of  elongation  of  the  peritonaeal  folds  which 
normally  hold  the  organ  in  place  and  of  elongation  of  the  splenic  vessels. 
It  may  occur  as  a  part  of  a  general  visceroptosis,  as  a  result  of  tight  lacing, 
traumatism,  or  of  increase  in  size  and  weight  of  the  organ.  The  displaced 
spleen  may  be  found  in  almost  any  part  of  the  abdominal  cavity  and  has  even 
been  observed  as  part  of  the  contents  of  an  inguinal  hernia. 

Symptoms.  The  symptoms  may  be  indefinite,  consisting  of  a  dragging 
sensation  in  the  abdomen;  pressure  symptoms  are  not  infrequent.  The  tumor 
may  impinge  upon  the  bladder  or  ureter  and  cause  difficulty  in  urination; 
pressure  upon  the  stomach  and  intestine  may  result  in  digestive  disorders 
or  partial  obstruction.  The  nervous  syndrome  which  is  observed  in  instances 
of  visceroptosis  may  occur.  Torsion  of  the  pedicle  of  the  organ  leads  to 
swelling,  fever  and  even  necrosis. 

Physical  examination  reveals  the  presence  of  a  movable  (unless  the  spleen 
has  become  fixed  by  adhesions  in  an  abnormal  position)  abdominal  tumor, 
the  shape  of  which  corresponds  to  that  of  the  spleen  and  whose  edge  is  sharp 
and  notched.  More  or  less  enlargement  of  the  displaced  organ  is  common. 
Percussion  over  the  normal  splenic  area  shows  an  absence  of  dulness. 

The  prognosis  as  to  life  is  good.  Twisting  of  the  pedicle  or  intestinal 
obstruction  due  to  pressure  are  serious  considerations. 

Treatment.  When  the  splenoptosis  is  a  part  of  a  general  downward  dis- 
placement of  the  viscera  the  treatment  is  that  of  the  latter  condition.  Simple 
wandering  spleen  may  often  be  held  in  place  by  means  of  a  properly  fitting 
pad  and  abdominal  belt. 


526  DISEASES    OF    THE    DUCTLESS    GLANDS. 

The  operative  treatment  by  means  of  splenectomy  has  given  good  results 
but  is  not  to  be  undertaken  without  due  consideration  since  enormous  haemor- 
rhages are  apt  to  occur  during  and  after  operation.  A  less  radical  pro- 
cedure is  opening  the  abdomen,  replacing  the  spleen  and  holding  it  in  position 
by  means  of  gauze  pads  until  permanent  adhesions  have  taken  place.  The 
pads  may  then  be  removed  and  the  abdominal  wound  closed. 

PERISPLENITIS. 

Perisplenitis  may  result  from  extension  of  inflammation  of  adjoining  struc- 
tures such  as  the  stomach,  diapliragm,  peri-renal  tissue  or  from  traumatism. 
Adhesions  result  and  pain  upon  respiratory  movements  may  distress  the 
patient.     Crepitus  over  the  spleen  may  be  detected  upon  palpation. 

Treatment.  The  pain  may  be  relieved  by  the  various  forms  of  mild  counter- 
irritation  and  the  inunctions  of  10  percent,  of  iodine  in  vasogen. 

SPLENITIS. 

Primary  inflammation  of  the  spleen  is  rare;  splenitis  secondary  to  inflam- 
mation of  adjacent  organs,  such  as  the  stomach  or  intestines,  may  take  place 
by  extension.  Traumatic  splenitis  may  occur  and  the  acute  hyperplasia  of 
the  organ  due  to  malarial  fever,  tvphoid  infection,  etc.,  may  be  considered  as 
an  inflammation  of  the  viscus. 

The  principal  symptoms  are  enlargement  and  tenderness  associated  with 
affections  of  neighboring  structures  or  occurring  in  the  coiirse  of  one  of  the 
infections. 

Physical  examination  reveals  the  presence  of  the  typical  splenic  tumor. 

When  the  organ  is  not  palpable  splenic  dulness  extending  below  Luschka's 
lines,  which  are  drawn  one  from  the  posterior  superior  iliac  spine  to  the  nipple, 
the  other  from  the  umbilicus  tangent  to  the  lower  border  of  the  eleventh  rib, 
gives  evidence  of  increase  in  size. 

Treatment  consists  in  the  proper  management  of  the  primary  condition. 
Ergot  in  drachm  (4.0)  doses  of  the  fluidextract  three  or  four  times  a  day,  given 
until  there  is  perceptible  arterial  hypertension,  will  cause  a  contraction  of  the 
organ.  The  administration  of  this  drug  preliminary  to  the  exhibition  of 
quinine  in  chronic  malarial  enlargement  is  an  excellent  measure.  Iodine 
may  be  prescribed  preferably  as  the  syrup  of  hydriodic  acid,  i  drachm  (4.0) 
three  times  daily  to  be  taken  on  an  empty  stomach  and  well  diluted. 

ABSCESS  OF  THE  SPLEEN. 

Abscesses  of  the  spleen  are  usually  metastatic,  occurring  in  general  pyaemic 
infections  or  in  malignant  endocarditis.     Simple  splenic  infarct,  which  may 


RUPTURE  OF  THE  SPLEEN.  527 

be  the  result  of  the  lodgment  of  a  non-septic  embolus  from  a  valvular  vegeta- 
tion in  endocardial  disease,  may  subsequently  become  infected  and  cause 
suppuration.  Splenic  abscess  may  also  result  secondarily  from  the  extension 
of  inflammation  of  neighboring  structures  or  from  traumatism.  Infective 
infarcts  may  also  occur  in  such  acute  diseases  as  enteric  fever. 

The  symptoms  of  splenic  suppuration  are  pain  and  tenderness  referred 
to  the  organ,  enlargement  and  a  temperature  of  septic  type.  Abscesses  of 
the  spleen  may  rupture  into  the  general  peritonasal  cavity.  The  rupture 
is  evidenced  by  sudden  pain,  prostration  and  abdominal  tenderness.  When' 
the  rupture  takes  place  into  the  stomach  pus  and  blood  may  be  vomited. 

Treatment  is  surgical  and  consists  in  free  incision  and  drainage. 

RUPTURE  OF  THE  SPLEEN. 

"This  accident  may  be  caused  by  severe  traumatism  or  occur  as  a  result 
of  marked  congestion  associated  with  enteric  fever.  It  may  also  be  due  to 
rapidly  growing  malignant  tumor  of  the  organ  and  has  been  known  to  follow 
exploratory  puncture. 

The  symptoms  are  severe  sudden  pain,  collapse  and  pallor,  resulting  from 
the  haemorrhage.  Death  takes  place  within  a  short  time  unless  immediate 
operation,  with  a  view  to  controlling  the  haemorrhage,  is  undertaken. 

THE  AMYLOID  SPLEEN. 

Synonym.     Sago  Spleen. 

The  amyloid  spleen  develops  in  association  with  amyloid  degeneration  of 
the  other  viscera  and  is  met  as  a  result  of  prolonged  wasting  disease  such  as 
chronic  tuberculous  inflammation  of  the  lungs  or  osseous  system,  chronic 
entero-colitis,  syphilis  and  protracted  suppurative  processes  generally.  The 
organ  is  enlarged,  hard,  smooth  and  firm;  its  edge  is  rounded. 

The  symptoms  are  those  of  the  causative  disease,  of  amyloid  degeneration 
of  other  viscera  with  emaciation,  weakness  and  splenic  enlargement. 

The  condition  is  a  serious  one  and  its  treatment  is  that  of  the  underlying 
affection. 

NEOPLASMS  OF  THE  SPLEEN. 

The  most  common  of  these  are  syphilitic  gumma  and  tuberculoma.  Cysts, 
echinococcus  and  of  other  types,  as  well  as  secondary  carcinoma  and  sarcoma 
have  been  observed.  The  condition  is  often  unrecognized  during  life.  The 
spleen  is  enlarged  and  its  surface  may  be  nodular.  The  diagnosis  depends 
upon  the  presence  of  associated  lesions.     Such  a  spleen  as  that  above  described 


528  DISEASES    OF    THE    DUCTLESS    GLANDS. 

occurring  with  gastric  cancer  may  be  attributed  to  carcinomatous  growths; 
in  the  presence  of  sarcomatous  tumors  elsewhere  it  is  probably  sarcomatous; 
when  observed  in  connection  with  specific  disease  it  may  be  considered  as 
syphilitic. 

ECHINOCOCCUS  CYSTS  OF  THE  SPLEEN. 

Echinococcus  infection  of  the  spleen  occurs  in  connection  with  similar 
disease  elsewhere  in  the  body.  The  organ  usually  presents  a  fluctuating 
tumor  the  character  of  which  cannot  be  definitely  determined  when  unasso- 
ciated  with  echinococcus  disease  in  another  organ,  or  unless  the  characteristic 
booklets  are  demonstrated  in  the  aspirated  fluid.  Abscess,  in  which  a  fluc- 
tuating enlargement  of  the  spleen  may  be  detected,  is  associated  with  the 
typical  temperatvure  of  pyogenic  infection. 

SPLENIC  ANEMIA. 

Synonym.     Splenic  Pseudo-leucaemia. 

Definition.  An  anaemia  characterized  by  enlargement  of  the  spleen  and 
to  be  differentiated  from  Hodgkin's  disease  and  leucaemia  by  the  absence 
of  increase  in  the  size  of  the  lymphatic  glands. 

.etiology.  While  the  definite  cause  of  the  affection  is  unknown  it  is  believed 
that  the  infectious  diseases  and  intestinal  infection  may  be  predisposing 
factors  in  its  occurrence. 

Pathology.  The  spleen  is  greatly  enlarged,  often  to  several  times  its  nor- 
mal size;  its  shape  is  not  affected.  Perisplenitis  with  capsular  thickening 
is  often  present  and  adhesions  to  adjacent  structiures  may  be  observed.  Upon 
section  the  organ  is  found  to  be  more  dense  than  normal  owing  to  increased 
connective  tissue  which  may  even  replace  the  Malpighian  bodies.  Sclerosis 
of  these  elements  is  characteristic  of  the  disease.  Changes  in  the  marrow 
analogous  to  those  met  in  pernicious  anaemia  may  be  noted.  Thrombosis 
of  the  splenic  vein  may  be  present. 

Symptoms.  These  are  a  gradually  increasing  pallor,  dyspnoea,  palpitation, 
progressive  weakness  and  enlargement  of  the  spleen.  The  patient  ultimatel) 
becomes  cachectic,  the  skin  is  yellow,  and  fever,  dropsy  of  the  subcutaneous 
tissue  and  of  the  serous  cavities  may  appear:  Haemorrhages  are  not  un- 
usual. 

The  blood  contains  a  relatively  high  number  of  red  cells  as  a  rule  (3,000,000 
to  3,500,000).  The  haemoglobin  percentage  is  lowered;  the  leucocytes  are 
are  not  increased  but  a  relative  lymphocytosis  may  be  present.  In  the  late 
stages  of  the  disease  poikilocytosis  with  normoblasts  and  megaloblasts  may 
be  observed  in  rare  instances. 


BANTI'S    DISEASE.  529 

The  diagnosis  is  distinctly  difficult  but  the  striking  features  of  the  condi- 
tion are  the  anaemia,  preceded  by  the  splenic  enlargement  and  the  absence  of 
increase  in  the  size  of  the  lymph  nodes,  with  a  diminished  or  normal  number 
of  leucocytes,  a  tendency  to  haemorrhages,  particularly  from  the  gastro-intes- 
tinal  tract,  and  a  protracted  course. 

The  prognosis  is  uniformly  unfavorable  but  the  patient  may  survive  for 
several  years. 

Treatment.  The  patient's  nutrition  should  be  maintained  by  plenty  of 
good  food  and  the  other  means  indicated  in  the  more  ordinary  types  of  anaemia. 
Arsenic,  iron  and  bone-marrow  may  be  prescribed. 

When  the  splenic  enlargement  is  marked  and  the  haemorrhages  are  severe 
and  frequent  the  operation  of  splenectomy  may  be  considered;  about  75  percent, 
of  recoveries  are  said  to  have  followed  this  procediure. 

BANTI'S  DISEASE. 

This  is  a  rare  affection  characterized  by  enlargement  of  the  spleen,  subse- 
quent anaemia  and  secondary  hepatic  cirrhosis  of  atrophic  type  with  jaundice, 
ascites  and  other  symptoms  of  this  lesion.  The  anaemia  is  analogous  to  that 
of  chlorosis  and  there  are  no  especial  leucocytic  changes.  Necropsy  has 
revealed  chronic  splenitis  with  interstitial  changes  in  the  liver  and  sometimes 
an  increased   redness  of  the  bone-marrow. 

The  course  of  the  disease  is  protracted,  lasting  ten  years  or  even  longer. 

The  indications  for  treatment  are  practically  identical  with  those  in  splenic 
anaemia. 

PSEUDO-LEUCiEMIA. 

Synonyms.  Hodgkin's  Disease;  Lymphatic  Anaemia;  Lymphadenosis; 
General  Lymphadenoma. 

Definition.  An  affection  characterized  by  enlargement  of  the  lymphatic 
glands  and  spleen,  the  appearance  of  lymphatic  growths  in  the  lungs,  liver, 
spleen  and  other  organs  and  a  consequent  secondary  anaemia. 

iEtiology.  The  causation  of  this  disease  is  unknown.  It  is  most  fre- 
quently observed  in  males  before  the  incidence  of  middle  life.  It  may  occur 
in  children.  In  numerous  instances  the  cervical  glands  are  first  involved 
following  some  buccal  or  pharyngeal  irritation,  which  fact  has  given  rise  to 
the  theory  that  the  affection  is  due  to  an  infection  which  effects  its  entrance 
through  the  structures  drained  by  the  cervical  lymphatics. 

The  hypothesis  that  tuberculous  infection  is  responsible  for  Hodgkin's 

disease  is  disproven  by  the  facts  that  the  tubercle  bacillus  is  not  constantly 

found  in  the  lesions,  that  inoculation  experiments  and  the  tuberculin  test  may 

be  negative  in  typical  instances  of  the  affection  and  that  the  pathological 

34 


53©  DISEASES    OF    THE    DUCTLESS    GLANDS. 

changes  in  the  glands  are  distinctive  and  characteris'ac.  Tuberculosis  may, 
however,  become  engrafted  upon  the  enlarged  glands  of  the  disease. 

Pseudo-leucaemia  is  likewise  to  be  separated  from  malignant  adenoma  by 
the  absence  of  the  characteristic  histologic  appearances  of  cancer. 

Pathology.  The  enlargement  involves  first  the  superficial  groups  of  lymph 
nodes,  those  of  the  neck  often  showing  increase  in  size  before  there  is  noticeable 
affection  of  those  of  the  axilla  and  groin.  Later  the  deep  glands,  those  of 
the  retro-peritonaeal,  bronchial  and  other  groups,  are  at  times  so  markedly 
increased  in  size  as  to  cause  abdominal  enlargement  or  respiratory  difiSculty. 
Pressure  upon  the  trachea,  oesophagus,  thoracic  vessels,  ureters,  and  lumbar 
nerves  may  occur.  At  first  the  diseased  lymph  nodes  are  soft  but  later  become 
hard  and  firm;  they  often  tend  to  fuse  and  they  seldom  become  adherent  to 
neighboring  structures.  When  cut  the  section  is  grayish  white  and,  if  the 
gland  is  soft,  a  whitish  fluid  exudes;  the  hardened  glands  are  firm  under  the 
knife  and  show  fibrous  trabeculae. 

Splenic  enlargement  is  present  in  a  large  majority  of  instances  and  is  of  the 
hyperplastic  type.     It  is  often  considerable  but  less  extreme  than  in  leucaemia. 

The  marrow  of  the  long  bones  is  sometimes  converted  into  lymphoid  tissue 
and  may  be  much  softened. 

Lymphoid  growths  are  present  in  the  spleen  in  more  than  50  percent,  of 
the  patients  and  these  may  occur  in  the  liver,  which  at  times  is  found  enlarged, 
the  kidneys,  the  lungs  and  other  organs  and  tissues.  Even  the  nervous 
system  may  be  invaded  and  the  lymphoid  structures  in  the  pharynx  often  under- 
go marked  increase  in  size. 

Symptoms.  The  first  of  these  is  usually  an  enlargement  of  the  cervical 
lymph  nodes  which  often  follows  an  inflammation  of  the  tonsils  or  pharynx. 
Rarely  the  deep  glands  are  first  involved.  Later,  but  perhaps  not  for  months 
or  even  years,  the  axillary  and  inguinal  glands  are  affected.  The  enlarge- 
ment may  cease  for  a  time  and  later  begin  again.  The  glands  usually  are 
soft,  discrete  and  very  seldom  are  painful  or  tender.  Late  in  the  disease 
they  may  become  hard  and  firm. 

The  spleen  is  usually  enlarged  and  the  lymphoid  growths  upon  the  surface 
of  this  organ  and  the  liver  may  be  palpable. 

As  the  affection  progresses  the  patient  becomes  anaemic,  is  pale,  and  com- 
plains of  weakness,  vertigo,  palpitation  and  dyspnoea. 

Pressure  symptoms  often  become  evident;  the  axillary  enlargement  causing 
pain  in  the  arms  and  hands,  by  reason  of  pressure  upon  the  nerves,  and  oedema 
due  to  interference  with  the  circulation.  Analogous  manifestations  are 
observed  in  the  lower  limbs  resulting  from  the  inguinal  enlargement.  Pres- 
sure upon  the  bronchi  or  trachea  causes  cough  and  dyspnoea.  Transudates 
may  appear  in  the  serous  cavities  and  pupillary  disturbance  from  pressure 
upon  the  sympathetic  may  be  noted.     Involvement  of  the  vagus  may  cause 


PSEUDO-LEUC^MIA. 


531 


a  disturbance  of  the  cardiac  action.     The  skin  may  become  bronzed;  crops 
of  furuncles  and  pruritus  have  been  noted. 

The  temperature  in  the  early  stages  is  irregularly  elevated  from  time  to 
time  to  a  slight  degree;  later  there  is  a  more  marked  febrile  movement,  a  daily 
ascent  of  several  degrees  with  chills  and  perspiration,  being  not  unusual. 
Rarely  paroxysms  of  fever  occur  lasting  for  a  week  or  two.  These  appear  at 
intervals,  the  temperature  during  the  intervening  periods  remaining  normal; 
coincident  with  the  fever  there  may  be  a  rapid  enlargement  of  the  glands 
which,  to  some  extent  but  not  wholly,  disappears  during  the  afebrile  period. 
Such  febrile  paroxysms  have  been  attributed  to  recurring  infection. 

The  late  stages  of  the  disease  are  marked  by  extreme  weakness  and  ema- 
ciation; general  oedema  is  sometimes  present. 

The  blood  shows  a  moderate  anaemia  of  chlorotic  type,  the  number  of 
red  cells  being  relatively  high  while  the  haemoglobin  percentage  is  low.  Changes 
in  the  form  of  the  red  cells  are  not  constant  nor  marked.  The  leucocytes 
usually  show  no  characteristic  change  in  number  or  in  type.  In  some  instances 
a  relative  lymphocytosis  has  been  observed;  an  ante  mortem  leucocytosis  has 
also  been  described. 

The  diagnosis  should  be  made  with  care,  there  being  several  conditions 
which  resemble  Hodgkin's  disease  suflSiciently  to  render  mistakes'  easy. 

Glandular  tuberculosis  may  be  differentiated  by  the  greater  tendency  of 
the  glands  to  coalescence  and  suppuration.  The  tuberculin  test  should  be 
employed  and,  if  necessary,  a  portion  of  the  involved  tissue  may  be  excised 
and  examined  microscopically. 

Malignant  disease  is  more  likely  to  be  limited  to  a  single  group  of  glands 
and  the  neighboring  structures  are  as  a  rule  invaded;  microscopical  examina- 
tion of  a  section  of  the  tumor  will  confirm  the  diagnosis.  In  lymphosarcoma 
the  lymphocytes  are  usually  considerably  increased  unless  there  is  involve- 
ment of  the  entire  lymphatic  apparatus,  when  these  elements  are  greatly 
reduced  as  a  result  of  the  disease  of  the  tissues  which  form  the  lymphocytes. 

Leucaemia  may  be  differentiated  from  Hodgkin's  disease  by  blood  exami- 
nation and  by  histological  examination  of  the  glandular  tissues  which  are 
affected. 

The  prognosis  is  distinctly  unfavorable  but  the  course  of  the  disease  is  not 
constant.  Certain  instances,  in  which  the  evolution  of  the  lymphoid  enlarge- 
ments is  rapid,  may  terminate  fatally  in  a  few  months  but  the  average  dura- 
tion of  life  after  the  onset  of  the  disease  is  about  two  years.  Temporary 
periods  of  remission  during  which  all  the  symptoms  become  ameliorated,  the 
swellings  diminish  and  the  patient  shows  marked  improvement,  are  not 
uncommon. 

Treatment.  The  general  management  of  this  affection  as  regards  hygiene, 
diet,  etc.,  is  identical  with  that  of  leucEemia.     Tonics  such  as  iron,  strychnine 


532  DISEASES    OF    THE    DUCTLESS    GLANDS. 

and.  codliver  oil  are  often  very  useful.  Bone-marrow  may  be  prescribed. 
Arsenic,  however,  seems  to  be  the  most  effective  drug  at  our  disposal.  Under 
its  administration  the  glandular  swellings  often  diminish,  the  condition  of 
the  patient  is  markedly  changed  for  the  better  and  the  course  of  the  disease 
is  retarded  even  if  recovery  does  not  ensue.  It  may  be  given  in  the  form  of 
Fowler's  solution  of  potassium  arsenite — in  increasing  dose^,  beginning  with 
3  or  4  minims  (0.2  to  0.25)  thrice  daily  after  eating.  It  should  be  well  diluted. 
The  dose  is  increased  each  week  by  i  minim  (0.065)  until  the  patient  is  taking 
20  to  30  minims  (1.33  to  2.0)  thrice  daily.  Upon  the  appearance  of  gastric 
disturbance  the  drug  should  be  stopped  and  later  resumed.  In  the  mean- 
time we  may  inject  the  Fowler's  solution  directly  into  the  glandular  tumor. 
The  proper  amount  is  slightly  less  than  that  to  be  given  by  mouth,  diluted 
with  an  equal  amount  of  sterile  water.  Arsenic  administered  in  this  way 
is  said  to  be  very  effective.  Sodium  dimethyl  arsenate  and  disodium  methyl 
arsenate  may  also  be  employed  as  suggested  in  the  section  upon  the  treatment 
of  pernicious  anaemia. 

Inunctions  of  10  percent,  iodine  in  vasogen  or  of  potassium  iodide  may 
have  some  influence  upon  the  glandular  enlargements  and  the  administration 
of  phosphorus  has  been  suggested.  Berberine  sulphate  is  advised  upon  the 
ground  that  it  betters  the  general  condition,  increases  the  appetite  and  lessens 
the  tendency  to  increase  in  size  of  the  spleen.  Its  dose  is  from  7^  to  15  grains 
(0.5  to  i.o).  It  may  be  prescribed  in  powder  mixed  with  milk  sugar  or  in 
pills  each  containing  3  grains  (0.2)  of  berberine  sulphate  and  2  grains  (0.13) 
of  extract  of  gentian.     Of  these  three  should  be  taken  thrice  daily. 

Symptomatic  cures  have  been  reported  .  as  resulting  from  Rontgen  ray 
treatment  and  improvement  is  said  to  take  place  in  many  instances.  A 
relatively  hard  tube  should  be  used  and  is  so  excited  as  to  give  a  light  pene- 
trating enough  to  reach  the  diseased  tissues.  The  ray  is  applied  to  the  enlarged 
glands,  the  spleen,  the  chest,  elbows  and  knees,  care  being  taken  to  avoid 
burns,  and  the  organs  of  generation  being  protected  by  an  opaque  screen. 
The  number,  intervals  and  duration  of  the  treatment  are  to  be  regulated 
in  accordance  with  the  effect  produced. 

When  the  lymphoid  enlargement  involves  the  neck  only,  particularly  if 
the  glands  of  only  one  side  are  affected,  excision  of  the  tumors  is  considered 
advisable  and  may  delay  the  progress  of  the  disease. 

STATUS  LYMPHATICUS. 

Synonym.    Lymphatism. 

Definition.  A  rare  affection  characterized  by  a  hyperplasia  of  the  various 
lymphoid  structures  and  tissues  of  the  body,  including  the  lymph  nodes,  the 
spleen,  the  thymus  gland  and  the  lymphoid  marrow  of  the  bones. 


STATUS    LYMPHATICUS. 


533 


Etiology.  The  condition  is  chiefly  observed  in  children  and  adolescents; 
nothing  definite  is  known  of  its  causation. 

Pathology.  The  lymphoid  tissues  of  the  pharynx  and  the  lymph  glands 
of  the  chest  and  abdomen  are  most  frequently  involved;  the  superficial  lymph 
nodes  are  seldom  affected.  Enlarged  tonsils  and  adenoid  growths  are  common 
and  the  solitary  and  agminated  glands  of  the  intestine  are  often  greatly  increased 
in  size.  The  splenic  hyperplasia  is  not  particularly  marked,  the  consistency 
of  the  organ  is  soft  and  the  Malpighian  corpuscles  are  distinct.  Enlarge- 
ment of  the  thymus  gland  is  the  rule,  the  structure  is  soft  and  upon  its 
cut  surface  a  milky  fluid  may  appear.  The  marrow  of  the  long  bones 
may  be  in  a  condition  of  hyperplasia  and  red  marrow  may  replace  the 
yellow. 

Associated  lesions  in  certain  instances  are  cardiac  and  aortic  hypoplasia 
and  rickets. 

The  chief  point  of  interest  concerning  the  status  lymphaticus  is  its  tendency 
to  association  with  sudden  death  from  apparently  inadequate  causes  such  as 
short  chloroform  or  aether  anaesthesia,  or  the  injection  of  a  dose  of  diphtheria 
antitoxin.  Instances  of  sudden  death  while  bathing,  or  upon  falling  into 
the  water  although  immediate  rescue  has  taken  place  have  also  been  attributed 
to  lymphatism.  The  so-called  "Thymus  Death"  of  the  Germans  has  been 
considered  a  result  of  this  condition  and  persons  who  have  died  suddenly 
during  the  convalescent  period  of  the  acute  infections  have  sometimes  been 
thought  to  have  possessed  this  affection. 

The  status  lymphaticus  has  been  considered  to  be  associated  with  a  condi- 
tion of  intermittent  lymphotoxaemia  or  due  to  excessive  production  of  the  secre- 
tion of  the  thymus  gland  and  it  has  been  supposed  tliat  the  sudden  death  is 
probably  the  result  of  such  toxaemia  or  occurs  as  a  result  of  toxic,  physical  or 
psychic  injuries  which  are  predisposed  toby  the  already  existing  lymphotoxaemia. 

The  recognition  of  the  condition  is  often  difficult  but  in  general  it  may  be 
stated  that  it  is  characterized  by  a  pale  and  pasty  skin,  a  considerable  amount 
of  subcutaneous  fatty  tissue,  hypertrophy  of  the  superficial  lymph  glands, 
especially  those  of  the  cervical  and  axillary  groups,  enlargement  of  the  tonsils, 
and  the  presence  of  pharyngeal  adenoids.  The  patient  is  often  rickety  and 
there  may  be  enlargement  of  the  spleen  and  of  the  thymus  gland.  Hyper- 
trophy of  the  deep  lymph  nodes  is  less  frequent  than  that  of  the  superficial 
groups  and  cardio-vascular  hypoplasia  is  very  inconstant,  although  the  state- 
ment has  been  made  by  Quincke  that  dilatation  of  the  left  ventricle  and  a 
shrunken  condition  of  the  peripheral  arteries  may  be  observed. 

Treatment.  This  is  based  upon  the  underlying  conditions.  Individuals 
in  whom  the  condition  is  suspected  should  not  be  subjected  to  general  anaes- 
thesia. If  surgical  operations  are  necessary  they  should  be  done  under  the 
influence  of  cocaine  or  some  analog-ous  drug;. 


534  DISEASES    OF    THE    DUCTLESS    GLANDS. 

DISEASES  OF  THE  THYROID  GLAND. 

SIMPLE  GOITRE. 

Synonyms.     Bronchocele;  Struma. 

Definition.  A  non-inflammatory  enlargement  of  the  thyroid  gland  occur- 
ring sporadically  or  endemically. 

.Etiology.  The  cause  of  simple  goitre  is  unknown  but  it  has  been  thought 
that  the  endemic  type  of  the  affection  may  be  due  to  some  constituent  of  the 
drinking  water.  Goitre  is  much  more  common  in  women  than  in  men  both 
in  its  sporadic  and  endemic  forms  and  the  most  common  time  for  its  develop- 
ment is  shortly  after  the  onset  of  puberty.  In  some  instances  the  swelling  does 
not  appear  until  the  incidence  of  the  menopause.  Heredity  may  have  some 
influence  in  its  production  and  congenital  instances  have  been  observed. 

In  the  United  States  endemic  goitre  is  infrequent  but  the  condition  is  not  rare 
in  regions  about  the  eastern  shore  of  Lake  Ontario,  Michigan  and  certain 
mountainous  districts  in  Pennsylvania.  It  is  very  common  in  certain  parts 
of  Switzerland,  France  and  Italy  and  may  occur  in  connection  with  cretinism. 
In  Derbyshire,  England,  it  is  observed  and  a  large  proportion  of  the  inhabi- 
tants of  some  portions  of  central  Asia  are  affected  with  the  disease. 

An  acute  epidemic  form  of  goitre  has  been  described  as  breaking  out  in 
schools  and  garrisons,  persisting  for  a  few  months  and  then  subsiding. 

Patients  afflicted  with  sporadic  goitre  are  quite  frequently  seen. 

Pathology.  Simple  goitre  begins  as  a  hypertrophy  of  the  parenchyma  of 
the  gland  but  as  the  enlargement  develops  certain  peculiarities  appear  result- 
ing in  goitres  of  various  types:  a.  Parenchymatous  ^ozVre  in  which  the  increase 
in  size  affects  aU  the  elements  of  the  gland  uniformly,  b.  Vascular  goitre 
in  which  the  enlargement  is  chiefly  the  result  of  dilatation  of  the  blood-vessels. 
c.  Cystic  goitre  in  which  the  follicles  become  enlarged  and  contain  fluid  and  in 
which  calcareous  degeneration  of  the  walls  is  frequent;  d.  Fibrous  goitre 
which  is  characterized  by  increased  grovrth  of  connective  tissue,  e.  Colloidal 
goitre  in  which  the  enlarged  follicles  are  distended  with  colloid  substance. 
Combinations  of  these  varieties  are  not  uncommon. 

Symptoms.  When  smaU,  goitrous  enlargements  usually  cause  no  symp- 
toms; large  goitres  cause  symptoms  which  are  chiefly  the  result  of  pressure 
upon  neighboring  structiu-es.  Pressure  upon  the  trachea  causes  difficulty 
in  breathing,  upon  the  oesophagus  interference  with  deglutition.  Extension 
of  the  tumor  behind  the  sternum  may  compress  the  veins  draining  the  head 
and  neck,  and  cause  swelling  of  these  parts,  with  vertigo  or  headache.  Rarely 
there  may  be  pressure  upon  the  vagus  resulting  in  paralyses  of  the  vocal  cords 
or  glottic  spasm.  Sudden  death  has  been  observed  in  rare  instances  and 
has  been  attributed  to  pressure  upon  the  pneumogastric  nerve  or  haemor- 
rhage. 


DISEASES    OF    THE    THYROID    GLAND.  535 

Examination  reveals  a  tumor  of  varying  size  which  rises  with  deglutition 
and  involves  either  the  entire  thyroid  gland,  one  or  both  lateral  lobes  or  the 
isthmus  alone.  In  cystic  goitre,  fluctuation  of  the  fluid  contents  of  the  cysts 
may  be  detected  and  in  the  vascular  type  pulsation  may  be  present. 

Treatment.  In  goitrous  regions  only  boiled  water  should  be  drunk  and,  if 
possible,  a  change  of  climate  should  be  advised;  even  after  the  appearance 
of  the  tumor  recovery  has  been  observed  upon  removal  to  a  non-goitrous 
district. 

Iodine  externally  and  internally  seems  to  have  more  influence  upon  the 
size  of  the  tumor  than  any  other  drug.  It  is  given  by  inunction  into  the  tumor 
in  the  form  of  the  ofiicial  iodine  ointment,  as  the  ointment  of  red  mercury 
iodide  or  in  an  ointment  consisting  of  i  part  of  iodine,  lo  parts  of  potassium 
iodide  to  loo  parts  of  lanolin  or  lard;  lo  percent,  iodine  in  vasogen  is  also 
suggested  as  an  inunction.  Internally  the  tinctiire  of  iodine  in  doses  of  from 
3  to  ID  minims  (0.2  to  0.66)  may  be  prescribed;  it  should  be  taken  twice  a 
day  after  eating  and  diluted  with  simple  syrup.  Potassium  iodide  in  doses 
of  from  10  to  20  grains  (0.66  to  1.33)  or  the  syrup  of  hydriodic  acid  in  doses 
of  I  drachm  (4.0)  in  a  wine  glass  of  water  before  meals  may  prove  useful. 

The  injection  of  iodine,  15  to  30  minims  (i.o  to  2.0)  of  a  10  percent,  alcoholic 
solution,  into  the  substance  of  the  gland  has  been  suggested.  The  procedure 
may  be  carried  out  two  or  three  times  per  week.  Iodoform  injections  have  been 
practised  and  are  particularly  indicated  in  the  cystic  type  of  the  affection; 
the  cyst  contents  having  been  drawn  off  by  means  of  an  aspirating  needle, 
30  minims  (2.0)  of  a  solution  containing  15  grains  (i.o)  of  iodoform,  if 
drachms  (7.5)  each  of  cether  and  sterile  olive  oil  are  injected  at  intervals  of 
from  one  to  two  weeks. 

In  vascular  goitre,  ergot  in  increasing  doses  may  be  administered  and 
belladonna  has  also  been  suggested. 

The  organotherapy  of  goitre  has  been  advocated  with  enthusiasm  and 
has  proved  beneficial  in  some  instances.  The  extract  of  the  thyroid  gland 
may  be  given  in  doses  of  from  3  to  5  grains  (0.2  to  0.33)  thrice  daily  or  the 
fresh  thyroid  of  the  sheep  chopped  and  spread  upon  bread  may  be  prescribed; 
75  to  150  grains  (5.0  to  lo.o)  of  the  gland  being  given  twice  weekly. 

The  use  of  electricity  may  be  tried  in  recent  goitrous  swellings  of  the  hyper- 
plastic type.  A  needle  attached  to  the  negative  pole  is  inserted  into  the  gland, 
the  positive  pole,  to  which  a  sponge  electrode  is  fitted,  being  applied  to  the 
skin  of  the  adjacent  parts.  The  galvanic  current  is  employed  and  the  result- 
ing electrolysis  may  diminish  the  size  of  the  tumor. 

Surgical  treatment  is  indicated  when  the  tumor  has  become  so  large  as 
to  cause  distress  by  its  pressure  or  disfigvu-ement.  The  entire  gland  may  be 
excised  if  desired  but  there  is  always  the  possibility  of  resulting  myxoedema 
or  cachexia  strumipriva.     In  vascular  goitre  particularly,  the  ligation  of  the 


53^  DISEASES    or    THE    DUCTLESS    GLANDS. 

thyroid  arteries  has  been  advised.  Other  surgical  procedures  which  may  be 
undertaken  are  partial  thyroidectomy,  incision  of  the  isthmus,  and  evacua- 
tion of  the  contents  of  cysts  followed  by  the  injection  into  their  cavities  of 
iodine  or  iron  chloride  solutions. 


CONGESTION  OF  THE  THYROID  GLAND. 

Congestion  of  the  thyroid  gland  is  often  observed  in  girls  at  puberty  and 
there  is  frequently  a  temporary  enlargement  coincident  with  the  menstrual 
period.  Such  enlargement  is  extremely  rarely  permanent.  Increase  in  the 
size  of  the  organ  has  also  been  observed  as  a  result  of  violent  and  prolonged 
weeping,  wearing  too  tight  collars  and  the  over-use  of  the  voice. 

ACUTE  THYROIDITIS. 

Acute  thyroiditis,  general  or  confined  to  one  lobe  of  the  gland,  is  evidenced 
by  acute  swelling,  tenderness  and  redness.  Rarely  suppuration  may  follow 
with  destruction  of  the  organ  and  resulting  myxoedema. 

This  affection  is  seldom  primary  but  is  a  not  very  infrequent  complication 
of  the  acute  infectious  diseases,  especially  enteric  fever,  scarlatina,  diphtheria 
and  pneumonia.     Exophthalmic  goitre  has  been  observed  as  a  sequela. 

EXOPHTHALMIC  GOITRE. 

Synonyms.     Graves'  Disease;  Basedow's  Disease;  Parry's  Disease. 

Definition.  An  affection  characterized  by  enlargement  of  the  thyroid 
gland,  protrusion  of  the  eyeballs,  rapid  pulse  and  tremors. 

.Etiology.  The  disease  is  much  more  frequent  in  women  than  in  men  and 
is  most  often  observed  in  young  and  middle-aged  adults.  Instances  have 
been  reported  in  early  childhood  and  in  old  age.  Heredity  has  some  influence 
as  a  predisposing  factor  and  the  condition  seems  more  likely  to  affect  those 
of  neurotic  tendency.  It  has  been  known  to  follow  such  acute  infections  as 
enteric  fever  and  rheumatism.  The  theory  that  exophthalmic  goitre  is  the 
result  of  intestinal  auto-intoxication  has  been  advocated  in  the  past,  but  the 
hypothesis  that  the  disease  is  a  specific  toxaemia  due  to  hyperthyroidism  or 
excessive  production  of  the  secretion  of  the  thyroid  gland  or  of  certain  elements 
contained  in  this  secretion,  is  the  most  recent  and  the  results  of  experimenta- 
tion seem  to  prove  that  this  is  the  true  cause  of  the  affection,  and  that  it  is  the 
antithesis  of  myxoedema  which  is  due  to  lack  of  proper  function  of  the  thyroid. 

Pathology.  The  changes  which  occur  in  the  thyroid  gland  in  exophthal- 
mic goitre  are  indefinite,  various  chronic  lesions,  however,  have  been  found. 


EXOPHTHALMIC    GOITRE,  537 

all  of  which  are  of  such  character  as  to  render  the  hypersecretion  theory  tenable. 
Persistence  of  the  thymus  gland  is  not  unusual  and  changes  in  the  muscles, 
probably  occurring  as  a  result  of  the  toxaemia,  may  account  for  the  extreme 
muscular  weakness  which  is  characteristic  of  the  disease. 

Symptoms.  Both  acute  and  chronic  forms  of  exophthalmic  goitre  are 
described;  in  the  former  the  onset  of  the  disease  is  very  rapid  with  pronounced 
exophthalmos,  greatly  increased  heart  action,  thyroid  enlargement  and  per- 
sistent vomiting  and  diarrhoea.  Cerebral  symptoms  are  not  usual  but  delirium 
appears  in  some  instances.  This  type  of  the  afifection  may  prove  fatal  within 
a  few   days. 

The  chronic  type  of  the  affection  is  usually  of  slow  development.  The 
"  characteristic  symptoms  are  four  in  number. 

1.  Rapid  heart  action  is  constant  and,  as  a  rule,  extreme,  the  pulse  rate 
often  reaching,  in  the  more  advanced  stages  of  the  disease,  100  beats  per 
minute  or  even  more.  Emotion  augments  the  pulse  rate  to  a  marked  degree. 
Irregularity  is  not  infrequent,  there  may  be  pulsation  in  the  vessels  of  the 
neck  and  visible  pulsation  of  the  superficial  arteries  and  of  the  capillaries 
is  often  present.  Physical  examination  reveals  a  forcible  apical  impulse 
which  is  in  marked  contrast  to  the  weakness  of  the  pulse.  The  apex  beat  is 
not  displaced  but  late  in  the  disease  may  be  diffuse.  Percussion  may  show 
cardiac  enlargement  due  to  a  secondary  hypertrophy  and  dilatation.  The 
heart  sounds  may  be  audible  at  a  distance  from  the  patient;  apical  ventriculo- 
systolic  murmurs  are  common  and  are  due  to  a  relative  mitral  insufficiency; 
basic  murmurs  of  soft  blowing  character,  usually  occurring  with  the  first 
sound,  are  common.  There  is  frequently  an  accentuation  of  the  sounds 
due  to  valvular  closure.  Acute  dilatation  may  supervene,  accompanied  by 
dyspnoea,  cough  and  the  expectoration  of  blood-stained  froth. 

2.  Exophthalmos  is  common;  it  may  not  develop  until  some  time  after 
the  incidence  of  the  cardiac  symptoms  and  it  varies  in  degree  in  different 
patients  and  even  from  time  to  time  in  the  same  subject.  It  may  be  slight, 
even  hardly  discernable,  or  very  extreme,  instances  of  entire  dislocation  of 
the  eyeball  having  been  observed.  The  patient  winks  more  seldom  than  in 
health;  the  pupil  and  the  vision  are  unaffected.  Optic  nerve  changes  are  not 
common  but  retinal  pulsation  is  often  observed.  Disturbances  of  conver- 
gence may  occur.  In  marked  instances  of  exophthalmos  the  eyelid  does  not 
follow  the  movement  of  the  eyeball  when  the  latter  is  moved  downward  (von 
Graefe's  sign).  This  is  characteristic  but  not  constant.  Retraction  of  the 
upper  lid  resulting  in  widening  of  the  palpebral  fissure  is  common  (Stellwag's 
sign).    Spasm  of  the  levator  palpebras  superioris  may  occur  (Abadie's  sign). 

3.  Thyroid  enlargement  usually  appears  with  the  exophthalmos;  the  increase 
in  size  is  usually  not  extreme.  The  enlargement  may  be  uniform  or  localized 
and  may  vary  with  changes  in  the  circulatory  function.     The  gland  may  be 


538  DISEASES    OF    THE    DUCTLESS    GLANDS. 

felt  to  pulsate  and  a  thrill  may  be  palpable,  auscultation  often  reveals  a  loud 
ventriculo-systolic  bruit;  a  double  murmur  may  be  detected  and  is  said  to 
be  pathognomonic. 

4.  Tremor  (Marie's  sign)  is  the  final  symptom  of  the  tetrad;  it  may  ap- 
pear early  or  not  until  late  in  the  disease.  It  is  observed  when  the  patient 
holds  out  his  hand  in  the  prone  position.  The  entire  hand  moves,  the  muscles 
of  the  wrist  being  the  ones  affected;  the  fingers  do  not  vibrate  independently. 
The  tremor  is  fine  and  of  small  extent;  its  rate  is  about  eight  or  nine  times 
per  second.     Rarely  the  foot  or  even  the  entire  body  may  be  involved. 

There  are  various  other  manifestations  associated  with  the  four  cardinal 
symptoms.  Muscular  weakness  and  painful  cramps  are  not  uncommon; 
even  muscvilar  atrophy  has  been  observed.  Flushing  of  the  skin  with  inter- 
mittent sweating  is  frequent  and  pruritus  and  pigmentation  may  occur.  A 
brawny  oedema  of  various  parts  is  often  noted  and  excessive  micturition  may 
take  place;  glycosuria  and  albuminuria  may  complicate  the  disease.  Rapid 
breathing  with  dyspnoea,  sometimes  accompanied  by  cyanosis,  is  not  rare, 
and  marked  diminution  in  the  cutaneous  resistance  to  electricity  has  been 
described  by  Charcot.  Mental  symptoms,  such  as  excitability,  depression, 
melancholia  and  mania  are  not  unusual  and  such  complications  as  epilepsy, 
hysteria  and  chorea  have  been  noted.  Symptoms  referable  to  the  digestive 
tract  such  as  those  which  usually  usher  in  the  acute  type  of  the  disease  may 
occur  from  time  to  time  in  the  chronic  form. 

Attacks,  which  strongly  indicate  the  probability  of  the  toxic  origin  of  the 
affection,  take  place  in  most  serious  types  of  the  disease  and  in  fatal  instances 
they  are  a  very  constant  manifestation;  they  are  frequently  induced  by  the 
incidence  of  some  mild  affection  such  as  tonsillitis,  bronchitis  or  influenza, 
and  consist  of  definite  febrile  exacerbations,  associated  with  acute  cardiac 
dilatation,  increased  intensity  of  the  existing  murmurs  or  the  appearance  of 
new  ones,  extreme  tachycardia  and  cardiac  distress,  digestive  disturbances, 
such  as  abdominal  pain,  vomiting  or  diarrhoea,  sweating,  dyspnoea,  rest- 
lessness and  sleeplessness,  erythema  of  the  skin  and  oedema  of  the  extremities. 
The  theory  is  that  such  exacerbations  of  symptoms  are  the  result  of  a  specific 
toxaemia  due  to  hj^erthyroidism. 

The  diagnosis  in  well-marked  instances  is  extremely  simple.  In  the 
masked  form  of  the  disease  difficulty  may  be  experienced,  for  at  times  the  rapid 
heart  action  and  tremor  may  be  present  without  thjToid  enlargement;  later, 
however,  the  goitre  may  appear  and  remove  the  doubt. 

The  prognosis  is  usually  good  as  to  life  but  recovery  is  rare  in  patients  in 
whom  the  disease  is  well  marked  and  has  persisted  for  a  considerable  period. 
Spontaneous  cure  sometimes  takes  place  in  the  mild  forms.  Acute  instances 
of  the  disease  and  acute  exacerbations  of  the  chronic  type  of  the  affection 
may  result  fatally  within  a  short  time;  yet  patients  in  whom  the  attack  appeared 


EXOPHTHALMIC    GOITRE.  539 

suddenly  and  gave  evidence  of  great  severity  have  gone  on  to  recovery  within 
a  few  days. 

Treatment.  The  importance  of  absolute  rest  cannot  be  too  strongly 
emphasized;  the  patient  should  be  put  to  bed  and  strict  quiet  enjoined, 
the  application  of  an  ice  coil  to  the  chest  and  the  administration  of  cardiac 
sedatives,  veratrum  viride  or  aconite,  will  lessen  the  cardiac  irritability,  while 
the  nervous  excitability  should  be  controlled  by  means  of  the  bromides.  Digi- 
talis and  strophanthus  have  been  advised  upon  account  of  their  action  in 
slowing  the  pulse  rate  but  these  drugs,  and  aconite  and  veratrum  viride  as 
well,  should  be  given  with  great  care.  The  use  of  ergot  has  been  advised 
and  good  results  have  followed  its  use  in  combination  with  strychnine  and 
digitalis;  the  same  is  true  of  belladonna  and  sodium  phosphate.  Relief  is 
said  to  have  followed  the  administration  of  sodium  salicylate  in  doses  of  10 
to  15  grains  (0.66  to  i.o)  3  or  4  times  daily  and  20  grain  (1.33)  doses  of  sodium 
glycerophosphate  given  at  similar  intervals,  are  recommended. 

Treatment  by  means  of  thyroid  extract  or  by  ingestion  of  the  gland  itself 
has  been  tried  but  has  proved  unsuccessfiil  save  in  instances  where  there 
have  been  myxoedematous  manifestations.  Suprarenal  extract  has  been 
employed  and  has  proved  sometimes  beneficial,  and  the  same  may  be  said  of 
thymus  extract. 

Electricity  has  given  good  results  in  some  instances  and  the  use  of  both 
the  faradic  and  galvanic  currents  as  well  as  of  the  sinusoidal  current,  has  been 
advocated.  Faradic  electricity  has  been  employed  as  follows:  the  positive 
pole  is  placed  in  the  nuchal  region  while  the  negative  pole  is  applied  to  the 
sterno-mastoid  muscle  at  the  angle  of  the  jaw,  thence  it  is  moved  to  the  middle 
of  the  muscle,  the  application  being  continued  for  about  a  minute  on  each 
side  of  the  neck;  the  negative  electrode  is  then  applied  to  the  eyelids  and 
around  the  margin  of  the  orbits  for  about  two  minutes  for  each  eye,  the  infra- 
and  supra-orbital  nerves  being  avoided.  A  plate  electrode  is  then  substituted 
for  the  olive  shaped  one  previously  employed  and  is  placed  over  the  thyroid 
tumor  and  allowed  to  remain  for  about  five  minutes.  This  form  of  treatment 
should  be  continued  for  from  six  months  to  a  year. 

The  galvanic  current  is  believed  to  exert  a  more  active  effect  upon  the 
glandular  secretion  and  has  given  good  results  in  the  hands  of  some  ob- 
servers. The  technique  is  variable  but  as  a  rule  the  negative  electrode  is 
applied  to  the  region  of  the  thyroid  and  the  positive  to  the  back  of  the  neck. 
The  strength  of  the  current  may  vary  from  25  to  60  milliamperes.  Guilloz 
moistens  the  negative  electrode  with  a  solution  of  potassium  iodide. 

A  combination  of  faradization  and  galvanization  may  be  employed,  a  large 
plate  electrode  being  applied  to  the  th}Toid  region  and  the  positive  electrode 
is  placed  at  the  back  of  the  neck.  A  galvanic  current  of  15  to  30  milliam- 
peres is  used  and  the  faradic  current  is  given  to  the  limit  of  the  patient's  toler- 


540 


DISEASES    OF    THE    DUCTLESS    GLANDS. 


ance.  In  some  subjects  this  treatment  brings  about  a  marked  amelioration 
within  two  or  three  months,  the  general  irritability  being  lessened,  together 
with  the  sense  of  oppression  and  the  diarrhoea,  and  the  goitre  diminishing  in  size. 
The  tachycardia  and  the  tremors  react  more  slowly. 

Quick  and  permanent  results  are  said  to  follow  the  use  of  the  sinusoidal 
current,  the  patient  being  placed  in  a  bath  of  water,  the  whole  body  surface 
thus  receiving  the  benefit  of  the  treatment. 

The  electricity  is  supposed  to  be  favorable  in  that  it  excites  the  rapid  elimi- 
nation of  the  thyroid  toxins  and  that  the  treatment  also  has  a  certain  mental 
effect  upon  the  patient  through  suggestion. 

The  Rontgen  rays  have  been  used  in  the  treatment  of  exophthalmic  goitre 
in  various  ways.  In  the  milder  types  of  the  affection  they  may  be  employed 
energetically  in  connection  with  regulation  of  the  patient's  general  hygiene; 
in  the  severer  instances  of  the  disease,  after  the  extirpation  of  a  portion  of  the 
gland,  the  exposures  are  begun  as  soon  as  the  wound  has  well  united.  The 
exposiure  of  the  gland  to  the  influence  of  the  rays  for  twelve  minutes  every 
four  to  seven  days  has  caused  a  complete  disappearance  of  the  thyroid 
tumor  in  at  least  one  instance. 

Tubes  containing  radium  have  been  inserted  into  the  incised  gland  for  a 
period  of  fifteen  minutes  and  after  several  weeks  of  the  treatment  a  diminution 
of  the  tumor  has  been  observed  but  the  tachycardia  has  persisted. 

Upon  the  toxaemic  theory  as  a  basis  numerous  experiments  along  the  line 
of  treatment  by  means  of  the  blood  or  serum  from  thyroidectomized  animals 
have  been  undertaken  and  some  of  these  have  produced  rather  remarkable 
results.  The  serum  appears  to  be  preferable  to  the  blood  since  it  is  more 
active  and  less  repugnant  to  the  patient.  The  serum  may  be  either  that  of 
the  goat  or  the  sheep;  the  best  results  are  said  to  be  obtained,  however,  from 
that  of  the  latter.  The  animals  operated  upon  should  be  between  the  ages 
of  two  and  five  years.  The  thyroid  is  wholly  excised  but  the  parathyroids  are 
left  in  place.  The  blood  is  first  drawn  by  means  of  jugular  puncture  about 
three  or  four  weeks  after  operation;  the  serum  is  filtered  and  rendered  absolutely 
sterile;  the  addition  to  it  of  antiseptics  such  as  phenol  does  not  seem  to  impair 
its  efficiency.  The  dosage  varies  from  35  to  45  minims  (2.33  to  3.0)  every 
two  days  depending  upon  the  patient's  condition,  and  the  serum  is  taken  in  water 
or  wine.  The  serum  is  continued  in  this  dosage  for  from  three  to  four  weeks;  it 
may  then  be  discontinued  for  a  week  and  later  resumed  for  two  weeks  in  each 
succeeding  month.  The  entire  duration  of  the  treatment  is  variable  but 
usually  is  from  six  months  to  a  year,  the  periods  of  intermission  being  length- 
ened as  the  patient  improves.  Under  the  influence  of  the  serum  the  size 
of  the  thyroid,  the  exophthalmos,  the  tachycardia  and  the  tremors  diminish 
progressively.  After  the  establishment  of  cure  it  is  best  to  advise  the  patient 
to  take  the  serum  for  about  fifteen  days  during  each  following  year. 


MYXCEDEMA.  541 

The  milk  of  th}Toidectomized  animals  has  also  been  employed  as  a  means 
of  treatment,  but,  while  to  a  certain  extent  effective,  is  inferior  to  the  serum. 

Very  recently  most  remarkable  results  have  been  reported  from  the  admin- 
istration of  a  cytotoxic  serum  produced  by  passing  an  extract  of  the  thjToid 
gland  of  human  beings  who  have  died  while  afflicted  with  exophthalmic  goitre 
through  the  blood  of  living  rabbits;  from  these  a  serum  is  derived  containing 
both  a  cytotoxin  and  an  antitoxin.  This  serum  when  injected  in  doses 
of  7h  to  30  minims  (0.5  to  2.0)  into  patients  suffering  from  exophthalmic 
goitre,  especially  those  who  exhibit  the  symptoms  of  febrile  exacerbations, 
produces  a  most  extraordinary  reaction.  Although  for  the  first  few  days 
after  administration  the  serum  may  seem  to  accentuate  the  symptoms,  a  general 
improvement,  even  recovery,  takes  place,  in  most  instances,  oftentimes  only 
two  or  three  doses  being  necessary  to  cause  this  effect.  The  only  untoward 
effect  of  this  treatment  seems  to  be  an  erythema,  not  only  at  the  site  of  the 
injection,  but  upon  remote  parts  of  the  body.  The  work  done  by  Rogers  and 
Beebe  upon  this  serum  bids  fair  to  revolutionize  our  theories  concerning  the 
origin  and  management  of  exophthalmic  goitre.  The  only  drawback  to 
this  method  of  treatment  would  seem  to  be  the  manifest  difficulty  of  obtaining 
diseased  human  thyroid  glands,  for  experiments  of  analogous  character  have 
been  undertaken  with  extracts  of  the  healthy  human  gland,  and,  while  not 
wholly  negative,  have  been  by  no  means  so  remarkable  in  their  resiilts  as 
those  with  the  extract  of  the  th^Toid  gland  of  exophthalmic  goitre. 

The  surgical  treatment  of  the  disease  must  be  considered  in  the  event  of 
the  failure  of  treatment  by  other  means.  Ligation  of  the  thyroid  arteries  is 
productive  of  benefit  in  some  instances  and  bilateral  sympathectomy  may 
produce  good  results  in  that  the  consequent  ptosis  will  diminish  the  exoph- 
thalmos; entire  recoveries  have  been  reported  as  due  to  this  operation.  It 
appears,  however,  that  the  most  effective  surgical  measure  is  partial  thyroi- 
dectomy. While  death  takes  place  following  the  operation  in  a  small  propor- 
tion of  the  patients  so  treated,  a  large  number  of  complete  cures  has  been  ob- 
served and  improvement  follows  the  procedure  almost  without  exception.  Sup- 
plementary operation  becomes  necessary  in  some  instances.  Complete 
thyroidectomy  would  seem  inadvisable  because  of  the  possibility  of  producing 
myxoedema. 

MYXCEDEMA. 

Synonyms.    Athyrea;  Cachexia  Thyroidea  vel  Strumipriva  vel  Thyreapriva. 

Definition.  A  constitutional  disease  characterized  by  dryness  of  the  skin, 
myxoedematous  infiltration  of  the  subcutaneous  tissues  and  atrophy  of  the 
thyroid  gland. 

.Etiology.     The  specific  cause  of  this  affection  is  disease  or  removal  of  the 


542  DISEASES    OF    THE    DUCTLESS    GLANDS. 

thyroid  gland  resulting  in  the  deprivation  of  the  body  of  the  normal  secretion 
of  this  organ. 

Pathology.  Autopsy  discloses  the  presence  of  a  mucous  oedema  of  the 
subcutaneous  connective  tissues  and  absence  or  atrophy  of  the  thyroid  body. 
In  cretins  the  pituitary  body  has  been  found  enlarged  and  the  cerebral  con- 
volutions may  be  indistinct.  The  lack  of  development  of  the  nervous  system 
may  be  associated  with  a  similar  condition  of  the  blood-vessels  of  the  brain. 

Symptoms.     Three  types  of  the  condition  may  be  described. 

1.  The  Myxoedema  of  Adults  (Gull's  Disease).  This  form  of  the  affection 
is  much  more  common  in  women  than  in  men  and  is  observed  chiefly  dtiring 
young  adult  life  and  middle  age.  Several  instances  may  occvir  in  one  family 
and  heredity  through  the  female  line  is  sometimes  a  factor  in  its  incidence. 
It  seems  to  bear  no  relation  to  the  genital  system. 

The  onset  may  be  characterized  by  the  symptoms  of  exophthalmic  goitre 
but  with  the  appearance  of  the  myxoedema,  which  involves  the  face  especially, 
although  the  other  parts  of  the  body,  including  the  tongue  and  at  times  the 
viscera  may  be  affected,  the  countenance  becomes  swollen.  This  is  the  result 
of  a  firm  infiltration  of  the  subcutaneous  tissues  with  a  mucoid  substance 
which  causes  a  broadening  and  flattening  of  the  face,  together  with  a  loss 
of  expression.  The  lips  and  nose  become  thickened  and  the  myxoedema 
of  the  skin  of  the  neck  produces  folds  which  may  even  extend  below  the  clavicle. 
The  skin  itself  becomes  dry  and  scaly  and  may  assume  a  yellowish  color  and 
a  waxy  appearance;  a  reddish  flush  is  sometimes  present  upon  the  cheeks 
and  nose  and  the  nutrition  of  the  hair  is  imperfect.  The  hands  and  feet 
become  misshapen,  movement  is  slow  and  the  mentality  becomes  sluggish. 
The  memory  is  impaired  and  the  disposition  irritable  and  suspicious;  hallu- 
cinations and  even  dementia  may  ultimately  appear.  There  is  no  febrile 
movement,  indeed  the  temperature  is  often  subnormal  and  the  patient  is 
very  susceptible  to  the  influence  of  cold.  There  is  no  interference  with  the 
functions  of  the  various  organs  although  albuminuria  and  glycosuria  may 
be  observed.  The  thyroid  gland  is  atrophied  and  may  become  converted 
into  fibrous  tissue. 

The  course  of  the  affection  is  slow  and  is  usually  prolonged  over  a  period 
of  a  number  of  years,  death  taking  place,  as  a  rule,  from  intercurrent 
disease. 

2.  Cretinism.  The  cretinoid  condition  is  a  result  of  absence  or  a  loss  of  func- 
tion of  the  thyroid  gland  and  may  evidence  itself  at  birth  or  make  its  appear- 
ance during  childhood.  It  is  a  type  of  idiocy  characterized  by  an  impairment 
of  both  physical  and  mental  development.  At  birth  cretinism  may  fail  of 
recognition  but  by  the  time  the  child  has  reached  the  age  of  a  few  months 
it  becomes  evident  that  the  growth,  mental  as  well  as  bodily,  is  not  normal; 
the  face  is  large  and  of  unintelligent  expression,  the  size  of  the  tongue  is 


MYXCEDEMA.  543 

increased  and  the  organ  protrudes,  the  skin  is  dry  and  the  hair  scanty; 
gradually  these  manifestations  become  more  and  more  apparent  and  by  the 
time  the  patient  has  become  two  or  three  years  old  the  condition  is  quite  unmis- 
takable. In  addition  to  the  characteristics  mentioned  above,  the  lips  become 
thickened,  the  eyelids  puiify,  the  nose  flat  and  the  neck  thick.  The  child's 
limbs  are  short  and  the  abdomen  is  protuberant;  the  extremities  are  poorly 
developed,  dentition  and  the  closure  of  the  fontanelles  are  delayed.  The 
muscles  are  weak  and  as  a  consequence  the  child  does  not  walk  until  late. 
Fatty  pads  are  present  above  the  clavicles  and  the  arrest  of  mental  develop- 
ment results  in  various  types  of  idiocy.  The  cretin  may  live  to  adult  life  but 
remains  dwarfed  in  body  and  mind. 

Atrophy  of  the  thyroid  gland  may  occur  in  previously  healthy  children  as  a 
result  of  one  of  the  acute  infections  and  subsequent  critinism  has  been  ob- 
served. 

The  cretinoid  state  occurs  in  two  forms,  the  sporadic,  which  is  the  type  de- 
scribed above,  and  the  endemic.  The  latter  form  is  met  in  regions  where  goitre 
is  also  endemic,  particularly  certain  parts  of  Switzerland,  France  and  Italy. 
Its  cause  is  unknown,  the  condition  developing  in  previously  normal  subjects 
coincident  with  change  in  the  thyroid  gland. 

Cretinism  is  easily  recognized  on  account  of  its  distinctive  characteristics; 
the  condition  which  most  closely  resembles  it  is  chondrodystrophia  fcetalis 
or  achondroplasia.  Here  the  limbs  are  short  and  curved  and  the  articulations 
are  enlarged  as  a  result  of  hypertrophy  of  the  cartilages  of  the  extremities 
of  the  bones.  The  affected  individual  is  dwarfed  but  there  is  no  such  lack 
of    mental    development    as   occurs   in   cretinism. 

3.  Cachexia  striimipriva  or  operative  myxcsdema  is  the  term  applied  to 
myxoedema  resulting  from  removal  of  the  thyroid  gland.  It  is  more  common 
after  total  thyroidectomy  than  when  only  a  part  of  the  gland  has  been  excised, 
but  does  not  result  in  every  instance  of  entire  removal  of  the  organ,  possibly 
because  portions  of  the  gland  have  been  inadvertently  allowed  to  remain  or  an 
accessory  thyroid  may  have  been  present. 

The  diagnosis  of  myxoedema,  on  account  of  the  very  characteristic  appear- 
ance of  the  patient,  is  simple.  The  oedema  of  nephritis  and  of  endocarditis 
pits  on  pressure  and  is  associated  with  the  presence  of  albumin  and  casts  in 
the  urine  (which  may,  however,  be  observed  in  myxcedema),  cardiac  symp- 
toms and  physical  signs;  there  is  no  lack  of  mental  and  bodily  development 
in  these  latter  affections. 

The  prognosis  under  proper  treatment  is  good,  the  results  obtainable  being 
little  less  than  marvelous. 

Treatment.  It  is  in  the  treatment  of  myxoedematous  conditions  that 
organotherapy  is  most  successfully  exemplified.  The  thyroid  gland  of  the 
sheep  is  chiefly  used  either  in  its  raw  form,  as  the  glycerin  extract,  or  in  tablets 


544 


DISEASES    OF    THE    DUCTLESS    GLANDS. 


made  from  the  cleaned,  dried  and  powdered  gland;  the  gland  itself  is  inferior 
to  either  of  the  other  preparations,  particularly  on  account  of  its  inconven- 
ience. The  usual  dose  of  the  glycerin  extract  is  from  15  to  30  minims 
(i.o  to  2.0)  daily;  that  of  the  dried  and  powdered  gland  about  4  grains  (0.25) 
three  times  a  day;  iodothyrin  in  dose  of  3  grains  (0.20)  may  be  employed. 
Unless  improvement  is  noted  within  a  short  time  the  dosage  should  be  increased 
until  there  is  distinct  amelioration  of  the  symptoms.  In  instances  which 
react  well  the  body  weight  diminishes,  the  skin  becomes  moist,  the  pulse  becomes 
more  rapid  and  there  is  distinct  improvement  in  the  mental  state.  At  the 
beginning  of  treatment  the  patient  should  be  carefully  observed  lest  heart 
failure,  of  which  a  few  instances,  following  excessive  dosage,  have  been  reported. 
As  a  rule  no  ill  effects  are  observed  but  sometimes  over-doses  produce  symp- 
toms analogous  to  those  of  exophthalmic  goitre,  cutaneous  irritation,  rest- 
lessness, rapid  heart  action  and  mental  excitation.  These  disappear  upon 
the  diminution  of  the  quantity  of  the  gland  administered.  Arsenic  when 
given  in  connection  with  the  preparations  of  the  thyroid  gland  is  said  to 
lessen  the  possibility  of  toxic  effects. 

As  the  symptoms  disappear  the  dosage  should  be  diminished  and  when 
cure  becomes  evident  our  object  should  be  merely  to  prevent  a  recurrence. 
Since  the  thyroid  gland  of  the  patient  is  absent  or  functionless,  it  follows 
that  when  the  treatment  is  stopped  we  are  practically  certain  to  be  confronted 
with  a  reappearance  of  the  symptoms  of  the  disease.  Such  a  circumstance 
may  be  prevented  by  the  administration  of  a  daily  small  dose  of  the  thyroid 
extract  or  powdered  substance.  The  amount  necessary  must  be  determined 
independently  for  each  patient  but  in  general  it  may  be  said  that  it  should 
be  sufficiently  large  to  prevent  the  occurrence  of  such  symptoms  as  an  abnor- 
mal temperature  and  subcutaneous  infiltration.  It  is  usually  necessary  to 
continue  this  second  stage  of  the  treatment  indefinitely. 

Myxoedematous  patients  suffer  more  in  cold  weather  than  in  warm,  conse- 
quently when  practicable,  they  should  seek  the  warmer  climates  and  when 
this  is  not  possible  all  means  should  be  employed  to  prevent  chilling  of  the 
body.  Warm  baths  and  frequent  massage  of  the  scalp  will  to  some  extent 
relieve  the  tendency  to  dryness  of  the  skin  and  improve  the  nutrition  of  the 
hair. 

Cretinism  should  be  treated  in  the  same  way  as  myxoedema  and  with  the 
same  precautions;  cretinoid  children,  however,  may  take  relatively  larger 
doses  of  the  thyroid  preparations  than  myxoedematous  adults.  The  results 
of  treatment  are  often  astounding  and  comprise  a  diminution  of  the  deformity, 
an  increased  growth  and  a  disappearance  of  the  idiotism.  The  treatment 
is  most  effective  when  begun  early.  Iodothyrin  is  said  to  be  less  apt  to  cause 
unpleasant  manifestations  than  the  glandular  substance  or  extract,  and  to  be 
quite  as  productive  of  good  results. 


NEOPLASMS    OF    THE    THYROID    GLAND.  545 

Cachexia  strumipriva  necessitates  the  thyroid  treatment  just  as  do  the 
other  types  of  myxcedema  and  its  continuance  for  the  remainder  of  the  patient's 
Hfe  is  usually  essential;  periods  of  intermission,  however,  are  often  advisable, 
the  reappearance  of  symptoms  being  the  signal  for  the  resumption  of  the 
thyroid  preparation  chosen. 

The  glycerin  extract  of  the  th}Toid  gland  may  be  made  by  separating  the 
connective  tissue  from  the  substance  of  several  dozen  thyroids  of  calves  or 
young  sheep;  these  are  divided  into  small  pieces  and  covered  with  pure  gly- 
cerin, about  30  minims  (2.0)  of  the  latter  substance  being  allowed  for  each 
lobe  used.  The  mixture  is  allowed  to  stand  for  thirty  hours  and  is  then 
pressed  through  a  cloth,  so  as  to  obtain  as  much  liquid  as  possible.  Of  this 
about  30  minims  (2.0)  constitute  a  dose.  The  fluid  may  be  given  hypoder- 
matically  by  adding  to  it  i  percent,  aqueous  solution  of  phenol  (carbolic  acid) 
in  the  proportion  of  60  minims  (4.0)  to  30  minims  (2.0),  the  dose  of  the  mixture 
being  from  10  to  15  minims  (0.66  to  i.o)  three  or  four  times  weekly. 

The  gland  substance  itself  may  be  given  raw  or  slightly  cooked.  When 
prescribed  thus  it  may  be  finely  divided  and  spread  on  bread,  the  daily  quan- 
tity being  from  one-fourth  to  one-half  a  gland  daily. 

Thyroid  grafting  has  been  employed  in  cretinism  and  myxcedema,  the 
fresh  gland  of  the  sheep  being  implanted  in  the  peritoneal  cavity  of  the  patient. 
Previous  to  the  operation,  thyroid  extract  should  be  given  until  the  symptoms 
of  the  disease  have  been  at  least  partially  relieved.  By  means  of  this  procedure 
a  temporary  disappearance  of  the  affection  has  been  effected;  ultimately,  how- 
ever, the  symptoms  have  usually  reappeared  and  a  second  operation  or  the 
administration  of  thyroid  preparations  has  become  necessary. 

NEOPLASMS  OF  THE  THYROID  GLAND. 

Various  new  growths  may  involve  the  thyroid  gland;  of  these  the  most 
common  are: 

1.  Adenoma.  This  type  of  tumor  is  usually  encapsulated  and  may  be 
either  single  or  multiple.  The  malignant  adenomata  may  be  associated  with 
metastases  in  different  parts  of  the  body. 

2.  Sarcoma  of  the  th}Toid  may  occur. 

3.  Tuberculoma  of  the  gland  has  been  noted  in  association  with  tuber- 
culosis of  other  structures,  but  is  rare. 

4.  Gummatous  timiors  of  syphilitic  origin. 

5.  Hydatid  cysts. 

All  these  are  of  little  medical  interest  and  their  treatment,  with  the  excep- 
tion of  the  tuberculous  and  S}^hilitic  growths,  is  surgical. 

Accessory  and  aberrant  thyroid  glands;  these  are  not  of  very  unusual  occur- 
35 


546  DISEASES   OF    THE    DUCTLESS    GLANDS. 

rence.  They  may  be  found  anywhere  between  the  base  of  the  tongue  and  the 
aortic  arch.  Tumors  of  thyroid  tissue  of  considerable  size  have  been  found 
in  the  mediastinum  and  pleura.  The  lingual  thyroid  may  grow  to  the  size 
of  a  pea  and  is  usually  situated  in  the  substance  of  the  lingual  muscles  or  is 
attached  to  the  hyoid  bone.  A  goitrous  condition,  characterized  by  moderate 
enlargement  of  this  structure,  has  been  observed  and,  in  the  absence  of  the 
normal  thyroid,  its  excision  has  resulted  in  myxoedema. 


DISEASES  OF  THE  THYMUS  GLAND. 

The  functions  of  this  structure  are  not  definitely  known.  The  organ 
increases  in  size  up  to  the  end  of  the  second  year,  weighing  at  this  time  in  the 
neighborhood  of  one  ounce  (30.0) ;  from  the  age  of  two  years,  it  gradually  shrinks, 
until  at  puberty  it  has  become  a  mere  bit  of  fatty  tissue. 

The  thymus  gland  is  subject  to  various  pathological  changes. 

Hypertrophy  of  the  gland  is  sometimes  observed  and  one  of  the  chief  points 
of  interest  in  this  condition  is  its  influence  in  the  production  of  thymic  asthma 
which  is  a  result  of  pressure.  Laryngismus  stridulus  has  also  been  attributed 
to  enlargement  of  the  gland;  certain  clinicians,  however,  believe  that  the 
latter  is  a  convulsive  affection  and  in  no  way  due  to  thymic  hypertrophy. 

Thymus  Death.  Instances  of  sudden  death  in  children  have  been  observed 
which  are  associated  with  hypertrophy  of  the  gland  and  sometimes  with  a 
hyperplastic  condition  of  the  entire  lymphatic  system  (see  the  section  upon 
Status  Lymphaticus).  Where  the  thymus  only  has  been  found  enlarged,  death 
has  been  thought  to  be  due  to  pressure  upon  the  trachea  or  upon  the  pneu- 
mogastric  nerve.  Epilepsy  is  sometimes  accompanied  by  a  persistently  enlarged 
thymus  gland  and  hyperplasia  of  the  other  lymphatic  tissues. 

Enlargement  of  the  gland  has  been  found  in  exophthalmic  goitre. 

Atrophy  of  the  thymus  gland  is  occasionally  observed  both  in  primary 
and  secondary  types.  The  former  is  believed  to  have  some  association  with 
marasmatic  conditions  and  the  latter  is  found  in  chronic  wasting  diseases 
such  as  tuberculosis. 

Haemorrhages  into  the  thymus  gland  occur  in  the  various  haemorrhagic 
diseases  and  have  been  noted  in  children  after  death  from  asphyxia. 

Abscess  of  the  gland  has  been  found  and  is  said  to  be  chiefly  associated 
with  instances  of  congenital  syphilis. 

Neoplasms,  such  as  sarcomata,  gummata  and  dermoid  cysts,  are  not  very 
uncommon  and  mediastinal  tumors  not  infrequently  develop  from  the  remnant 
of  the  gland. 

Tuberculous  inflammation,  characterized  by  the  production  of  miliary 
tubercles,  has  been  described. 


Addison's  disease.  547 

DISEASES  OF  THE  SUPRARENAL  CAPSULES. 
ADDISON'S  DISEASE. 

Definition.  A  chronic  affection  probably  the  result  of  non-function  of 
the  suprarenal  bodies  and  characterized  by  progressive  weakness,  pigmen- 
tation of  the  skin  and  digestive  irritability. 

Etiology.  The  disease  is  more  frequent  in  men  than  in  women  and  it 
usually  appears  during  young  adult  life  or  in  early  middle  age.  One  con- 
genital instance  has  been  reported.  The  onset  of  symptoms  may  be  subse- 
quent to  traumatism  of  the  abdomen  or  back  or  to  spinal  caries. 

Pathology.  The  most  common  post  mortem  lesion  is  tuberculosis  of 
the  suprarenal  capsules  with  fibro-caseous  and  calcareous  degeneration. 
Other  conditions  which  have  been  observed  are  cystic  and  fatty  degeneration, 
atrophy,  simple  or  preceded  by  a  chronic  interstitial  inflammation,  carci- 
noma, sarcoma,  haemorrhage  and  embolism.  In  some  instances  the  supra- 
renal bodies  have  been  found  normal  and  here  the  symptoms  have  been 
accounted  for  by  inflammation  of  or  pressure  upon  the  sympathetic  ganglia. 
Degeneration  and  pigmentation  of  the  semilunar  ganglia  and  sclerosis  of 
the  nerves  have  been  noted.  Cicatricial  tissue  about  the  suprarenals  may 
surround  the  ganglia.  An  enlargement  of  the  spleen  and  of  the  thymus 
gland  may  exist  as  associated  lesions. 

The  two  chief  theories  of  the  pathogenesis  of  Addison's  disease  are  (i)  that 
it  is  due  to  non-function  of  the  adrenals  just  as  myxcedema  is  the  result  of  a 
similar  condition  of  the  thyroid  gland;  (2)  that  it  follows  interference  with 
the  proper  working  of  the  abdominal  sympathetic  system  usually  caused  by 
disease  of  the  suprarenals  and  by  other  affections  of  the  solar  plexus. 

Symptoms.  The  onset  of  the  disease  is  usually  slow,  with  gradually  increas- 
ing asthenia  followed  by  cutaneous  pigmentation.  An  acute  type  of  the 
affection  has  been  described  in  which  a  rapid  evolution  of  the  symptoms  has 
taken  place  after  severe  shock  or  depression. 

The  discoloration  of  the  skin  is,  as  a  rule,  the  first  symptom  noticed;  this 
varies  from  light  yellow  to  dark  brown  or  even  black.  It  is  most  apparent 
upon  the  exposed  parts  such  as  the  face  and  hands,  in  other  situations  where 
pigment  is  normally  most  abundant  such  as  the  scrotum,  and  where  the  skin 
is  irritated  by  the  clothing.  Rarely  the  pigmentation  may  be  general  and  at 
times  it  is  wholly  absent.  It  is  often  found  upon  the  mucous  membranes  of 
the  mouth,  conjunctiva  and  vagina.  At  times  there  are  patches  of  leucoderma, 
the  normal  pigment  being  entirely  absent.  Very  infrequently  there  may  be 
deposits  of  pigment  in  the  serous  membranes  and  upon  the  discolored  skin 
there  may  be  small  spots  of  deeper  pigmentation. 

The   digestive   syrnptoms   consist    of   nausea   and   vomiting,    particularly 


548  DISEASES    OF    THE    DUCTLESS    GLANDS. 

marked  at  the  inception  of  the  disease;  diarrhoea  may  be  present  from  time 
to  time  and  anorexia  is  not  infrequent.  In  the  late  stages  abdominal  pain 
with  retraction  may  appear. 

Progressive  weakness  is  a  constant  and  characteristic  symptom  and  may 
become  so  extreme  that  the  patient  is  unable  to  leave  his  bed.  With  the  muscu- 
lar weakness  there  is  accompanying  cardiac  asthenia  with  feeble  heart  action, 
small  and  rapid  pulse,  dyspnoea,  dizziness  and  even  fatal  syncope.  Head- 
ache and  pain  in  the  back  are  common.     Convulsions  may  occur. 

The  condition  of  the  blood  is  usually  normal;  the  same  is  true  of  the  urine 
but  increase  in  the  contained  pigment  has  been  observed.  Polyuria  may 
occur. 

The  diagnosis  should  not  be  made  upon  the  presence  of  cutaneous  pig- 
mentation alone  for  there  are  many  conditions  of  which  this  is  an  accom- 
paniment. Of  these  may  be  mentioned  peritonjeal  tuberculosis,  abdominal 
malignant  growths,  melanotic  cancer,  pregnancy,  hepatic  disease,  bronzed 
diabetes,  vagabondism  with  marked  filthiness,  the  prolonged  administration 
of  arsenic,  exophthalmic  goitre  and  cardiac  and  arterial  disease.  All  these 
should  be  excluded  before  Addison's  disease  is  diagnosticated  and  even  then 
associated  symptoms — weakness  and  gastro-intestinal  disorders — should  be 
sought  before  arriving  at  a  definite  conclusion.  The  employment  of  the 
tubercuhn  test  may  clear  up  doubtful  instances  if  due  to  tuberculosis  of  the 
adrenals. 

The  prognosis  is  unfavorable  although  treatment  may  prolong  life  and 
make  the  patient  comfortable.  Marked  pigmentation  augurs  a  protracted 
course  and  patients  in  whom  this  manifestation  is  slight  or  absent  usually 
fail  rapidly.  There  are  patients  in  whom  the  evolution  of  the  affection  is  acute, 
the  symptoms  are  marked,  and  in  whom  death  takes  place  within  a  few  weeks. 
The  average  duration  of  the  disease  is  from  two  to  three  years.  Death  occurs 
as  a  result  of  the  increasing  weakness,  in  syncope  or  from  associated  tuberculous 
lesions. 

Treatment.  The  management  of  this  disease  should  be  so  carried  out  as 
to  conserve  the  patient's  strength  as  much  as  possible  and  to  sustain  the  proper 
functions  of  the  various  organs.  The  patient  should  live  a  quiet  life  and  all 
physical  and  mental  excitation  should  be  avoided  on  account  of  the  danger 
of  syncope.  In  the  later  stages  it  is  best  to  confine  the  patient  to  bed.  The 
diet  should  be  plentiful,  nourishing  and  easily  digestible;  during  the  periods 
of  gastric  and  intestinal  disturbance,  a  strictly  fluid  regimen,  consisting  of 
milk,  broths,  etc.,  shoidd  be  enjoined.  Iron  may  be  given  as  a  tonic  but, 
as  anaemia  is  seldom  a  prominent  feature  of  the  disease,  is  usually  less 
efficient  than  strychnine,  arsenic,  codliver  oil,  phosphorus  and  the  bitters. 
Acute  vomiting  and  diarrhoea  necessitate  a  diet  of  fluids  such  as  milk,  kou- 
myss,  matzoon,  peptonized  milk,  albumin  water,  etc.,  and  the  administration 


ADDISON'S    DISEASE.  549 

of  anti-emetic  drugs  such  as  cerium  oxalate,  of  which  lo  grains  (0.66)  may  be 
combined  with  20  grains  (1.33)  of  sodium  bicarbonate  and  added  to  each 
glass  of  milk;  in  this  connection  cracked  ice,  iced  champagne,  dilute  hydro- 
cyanic acid,  creosote  and  tincture  of  iodine  are  useful.  The  diarrhoea  may 
be  controlled  by  the  ordinary  means,  such  intestinal  disinfectants  as  phenyl 
salicylate  and  bismuth  naphtholate  being  especially  useful;  other  bismuth  salts 
are  also  effective.  The  muscular  weakness  may  be  combated  by  the  use  of 
electricity,   massage   and  hydrotherapeutic   measures. 

The  extraordinary  results  achieved  in  myxoedema  by  the  administration 
of  the  thyroid  gland  would  give  ground  for  hope  that  in  the  analogous  con- 
dition present  in  Addison's  disease  equally  good  results  might  follow  the 
use  of  the  suprarenal  extract.  Unfortunately  treatment  by  this  means  as  yet 
has  proven  of  little  benefit  but  it  is  quite  possible  that  the  results  of  future 
experimentation  may  be  more  favorable  than  those  achieved  up  to  the  present 
time.  Instances  have  been  cited  in  which  the  administration  of  a  glycerin 
extract,  made  from  the  suprarenals  of  the  pig  just  as  the  thyroid  extract 
(see  p.  543)  is  made,  given  in  doses  of  about  4  ounces  (120.0)  three  times  daily, 
was  followed  by  marked  improvement;  the  pigmentation,  however,  persisted. 
The  suprarenal  gland  may  be  taken  raw  or  slightly  cooked  or  the  gland  sub- 
stance may  be  prescribed  in  the  form  of  tablets  of  the  dried  extract.  The 
dose  of  desiccated  suprarenal  glands  is  4  grains  (0.25).  The  usual  daily 
dosage  of  the  suprarenal  preparations  is  about  the  equivalent  of  two  glands. 
While  no  curative  effect  should  be  promised  from  this  treatment,  a  trial  of  it 
should  never  be  omitted  as  no  evil  sequelae  result  and  much  benefit  may 
follow. 


550  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 


CHAPTER  VII. 

DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS. 

DISEASES  OF  THE  PERICARDIUM. 

ACUTE  PERICARDITIS. 

Definition.  An  acute  inflammation  of  the  serous  membrane  surrounding 
the  heart. 

Etiology.  This  affection  may  occur  primarily  as  a  result  of  tuberculous 
infection,  as  a  result  of  traumatism  either  external  or  internal,  from  the  migra- 
tion of  a  foreign  body  from  the  oesophagus,  or  perhaps  as  a  result  of  rheu- 
matic infection  which  manifests  itself  in  the  pericardium  instead  of  in  the 
articulations.    Idiopathic  instances  may  be  observed. 

Secondary  pericardial  inflammations  are  far  more  common  than  primary. 
They  may  occiu"  as  a  complication  of  acute  rheumatism,  accompanying  joint 
inflammation  or  tonsillitis;  as  a  complication  of  the  acute  infectious  diseases, 
particularly  scarlatina  and  acute  infectious  pneumonia;  in  septicaemia  and 
pyaemia;  in  tuberculosis;  with  chorea;  and  in  the  later  stages  of  various 
chronic  dyscrasiae  such  as  gout,  nephritis,  diabetes  and  the  haemorrhagic 
diseases. 

Pericarditis  also  occurs  as  an  extension  of  affections  of  neighboring  organs 
or  tissues,  e.g.,  in  chronic  endocarditis,  pleurisy,  pneumonia,  aneurysm,  etc. 
Inflammatory  processes  and  neoplasms  in  the  ribs,  oesophagus,  vertebrae, 
mediastinal  glands  and  even  of  structures  beneath  the  diaphragm  may  cause 
pericarditis  by  extension. 

The  disease  in  the  majority  of  instances  is  rheumatic  in  origin;  it  is  common 
to  all  ages  but  seems  to  attack  males  more  frequently  than  females. 

Pathology.  The  disease  may  be  considered  to  occur  in  three  stages.  First, 
the  membrane  is  congested  and  reddened,  it  becomes  roughened  and  an 
exudation  of  fibrin  involving  more  or  less  of  its  surface,  takes  place,  the  latter 
assuming  a  ridged  or  fringe-like  appearance.  The  heart  muscle  may  be  in- 
volved in  the  inflammation  to  a  slight  degree,  if  the  pericardium  is  markedly 
affected,  as  is  shown  by  an  anaemic  appearance.  In  tuberculous  instances  the 
miliary  tubercles  may  be  detected  by  close  scrutiny.  In  simple  fibrinous 
pericarditis  the  exudation  softens  and  is  absorbed,  leaving  behind  a  normal 
or  adherent  pericardium,  but  more  often  the  affection  passes  on  to  the  serous 
stage.     Here  there  is  added  to  the  plastic  exudate  an  effusion  of  serum,  which 


ACUTE    PERICARDITIS.  55 1 

distends  the  pericardial  sac  to  a  greater  or  less  extent.  This  fluid  is  amber- 
colored  and  clear,  although  in  it  there  may  occur  floating  particles  of  fibrin. 
This  effusion  may  be  absorbed,  the  pericardial  surfaces  being  left  adherent  in 
many  instances,  or  it  may  become  purulent.  The  adhesions  may  render  the 
two  layers  of  the  pericardial  sac  almost  like  a  single  thickened  membrane  or, 
villous  adhesions  resulting,  the  two  pericardial  layers  are  permitted  to  move 
one  upon  the  other  with  the  impulse  of  the  heart.  These  villous  adhesions 
are  composed  of  vascular  connective  tissue  which  is  produced  by  a  proliferation 
of  the  normal  connective  tissue  of  the  membrane  and  resemble  the  papillae 
of  a  sheep's  tongue  or  buttered  surfaces  of  bread  which  have  been  sepa- 
rated. 

Suppuration  may  be  primary  or  secondary,  the  effusion  being  purulent 
from  the  first,  or,  in  the  latter  instance,  pyogenic  infection  of  the  serous  fluid 
may  take  place  later.  In  tuberculous  pericarditis  the  exudate  may  undergo 
caseous  degeneration. 

The  pathogenic  bacteria  most  usually  found  in  acute  pericardial  inflam- 
mations are  the  ordinary  germs  of  suppuration,  the  tubercle  bacillus  and  the 
pneumococcus. 

Symptoms.  These  differ  with  the  pathological  condition;  while  pericar- 
ditis may  begin  with  a  chill  or  pain  referred  to  the  heart,  the  fibrinous  type 
often  exists  without  subjective  symptoms.  The  pain  may  be  merely  a  sense 
of  cardiac  discomfort  or  it  may  be  referred  to  the  ensiform  cartilage  or  to  the 
epigastrium.  The  temperature  usually  is  dependent  upon  the  primary 
affection;  in  primary  pericarditis  it  seldom  exceeds  102°  F.  (38.9°  C).  The 
pulse  is  increased  in  rapidity  and  dyspnoea  may  be  present.  Precordial 
tenderness  may  be  observed. 

Pericardial  effusions  by  pressure  interfere  with  the  heart's  action  causing  a 
rapid  and  perhaps  irregular  pulse.  With  inspiration  the  pulse  beat  may 
become  much  weakened  or  even  imperceptible  (pulsus  paradoxus).  Inter- 
ference with  cardiac  action  also  results  in  dyspnoea,  with  cyanosis,  and  the 
patient  may  prefer  to  lie  upon  the  left  side  or  may  be  unable  to  breathe  com- 
fortably unless  he  sits  up.  Large  collections  of  fluid  encroach  upon  the  left 
lung,  press  upon  the  oesophagus  causing  dysphagia,  or  upon  the  left  recurrent 
laryngeal  nerve  causing  aphonia.  The  patient  is  restless  and  sleepless,  and 
cerebral  symptoms,  even  delirium  and  coma,  may  be  present,  especially  in 
the  rheumatic  instances  with  high  temperature.  In  suppurative  pericarditis 
the  constitutional  symptoms  are  usually  more  marked  and  the  fever  is  of 
septic  type.  The  invasion  of  the  pyogenic  micro-organisms  may  be  evidenced 
by  a  chill. 

Physical  Signs,  a.  Of  -fibrinous  pericarditis.  Pressure  over  the  pre- 
cordium  or  over  the  ensiform  may  elicit  tenderness  and  upon  palpation  a 
rough    fremitus    corresponding    to   the  pericardial   friction   sound   may   be 


552  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

detected.  Auscultation  reveals  the  presence  of  the  pericardial  friction  sound; 
this  is  heard  with  greatest  intensity  over  the  left  half  of  the  sternum  at  the 
level  of  the  foiurth  and  fifth  intercostal  spaces  and  in  these  spaces  close  to  the 
sternum,  i.e.,  where  the  heart  most  closely  approximates  the  chest  wall;  it  is 
usiially  a  to-and-fro  murmur  but  may  be  single  or  even  triple.  In  quality 
it  is  rasping,  grating,  or,  more  rarely,  creaking;  the  sound  is  close  to  the  ear 
and  may  be  increased  in  intensity  by  the  pressure  of  the  stethoscope.  It  is 
not  constant  and  may  at  intervals  be  inaudible  or  change  in  its  quality  or 
intensity  from  time  to  time  or  with  the  poshion  of  the  patient.  Its  trans- 
mission varies;  it  may  be  localized  to  a  small  area  or  transmitted  in  various 
directions;  there  is  no  fixed  rule. 

b.  Of  pericarditis  with  the  effusion  of  fluid.  Here  the  physical  signs 
vary  with  the  quantity  of  the  fluid.  If  this  is  large,  and  especially  in  children, 
there  may  be  a  fulness  or  bulging  of  the  precordium  and  the  apical  impulse 
is  wav}'  or  perhaps  absent;  the  upper  border  of  the  first  rib  may  be  unduly 
prominent  (Ewart's  sign);  pressure  upon  the  left  lung  may  diminish  its 
expansion  and  downward  pressure  may  displace  the  left  lobe  of  the  liver  and 
cause  an  epigastric  prominence.  (Auenbrugger's  sign).  Palpation  reveals  a 
diminished  or  absent  impulse  and,  as  the  effusion  increases,  the  friction  thrill 
diminishes;  it  may  be  palpablate  the  base  only  and  then  only  when  the  patient 
is  sitting.  In  the  recumbent  position  it  is  likely  to  be  absent.  Upon  percussion 
an  increased  area  of  dulness  is  made  out,  this  is  irregularly  triangular,  the  base 
being  directed  downward  and  the  apex  upward.  Rotch's  sign,  an  absence  of 
resonance  in  the  fifth  right  space,  -may  be  present  and  there  may  be  an  area 
of  dulness  or  flatness  posteriorly  below  the  angle  of  the  left  scapula.  Auscul- 
tation. The  friction  sound  may  disappear  on  account  of  the  separation  of  the 
layers  of  the  pericardium  by  the  eflcusion  or  it  may  remain  audible  at  the  base. 
The  heart  sounds  are  indistinct  and  muffled  or  even  almost  inaudible.  The 
pulse  rate  is  increased  and  the  heart  action  may  become  arrhythmic.  A 
systolic  murmur  at  the  base  and  an  accentuation  of  the  second  pulmonic 
sound  may  be  present.  There  may  be  an  area  of  broncho- vesicular  or 
bronchial  breathing  posteriorly  below  the  angle  of  the  left  scapula  or  between 
this  point  and  the  vertebral  coliunn. 

As  the  fluid  gradually  is  absorbed  the  physical  signs  return  to  normal, 
either  with  or  without  the  reappearance  of  the  friction  murmur,  or,  if  per- 
manent pericardial  adhesions  are  formed,  the  physical  signs  of  this  condition 
may  be  apparent. 

The  diagnosis  of  pericarditis  is  often  overlooked,  consequently  in  all  instances 
of  acute  articular  rheumatism  daily  examination  of  the  heart  should  be  made. 
In  patients  in  whom  the  typical  to-and-fro  murmur,  heard  close  under  the  ear, 
is  present  the  diagnosis  is  simple,  but  unfortunately  the  characteristic  physical 
signs  are  often  absent;  here  the  direction  of  transmission  of  the  miurmur  is 


ACUTE    PERICARDITIS.  553 

of  aid,  there  being  no  rule  for  the  transmission  of  a  pericardial  murmur, 
as  also  is  the  fact  that  the  sound  becomes  louder  upon  pressure  with  the 
stethoscope.  The  so-called  "  pleuro-pericardial "  friction  sound  may  be  dis- 
tinguished from  the  pericardial  miirmur  by  the  facts  that  it  is  more  usually 
heard  over  the  left  border  of  the  heart  and  is  louder  during  expiration,  often 
being  absent  during  inspiration;  also  it  may  cease  upon  holding  the  breath, 
but  not  always  since  it  is  due  to  the  motion  of  the  heart.  The  differen- 
tiation of  pericarditis  with  effusion  from  acute  cardiac  dilatation:  in  the 
latter,  if  the  patient  is  thin,  the  apical  impulse  is  diffuse  and  undulatory,  while 
it  is  usually  indefinite  or  even  absent  in  pericarditis.  In  dilatation  the  apex 
beat  is  more  distinctly  palpable;  percussion  reveals  the  typical  triangular 
area  of  dulness  in  pericarditis,  the  upper  limit  of  which  may  change  with  the 
position  of  the  patient;  in  dilatation  the  dull  area  is  not  triangular  nor  does 
it  extend  so  high  or  so  low.  On  auscultation  the  heart  sounds  in  pericarditis 
are  muffled  and  indistinct  while  in  dilatation  they  are  much  less  so  and  may 
be  sharp  and  definite.  Dulness  and  changes  in  the  breath  sounds  below  the 
angle  of  the  left  scapula  and  tympany  in  the  axilla,  due  to  pressure  upon  the 
lung  by  the  effusion,  are  absent  in  dilatation.  Large  pericardial  effusions 
have  been  mistaken  for  localized  pleural  exudates.  The  character  of  the 
fluid  cannot  be  certainly  determined  without  paracentesis,  but  it  is  usually 
serous  in  rheumatic,  while  in  pyaemic  and  tuberculous  instances  it  is  likely  to  be 
purulent;  bloody  fluid  may  occur  in  tuberculous  pericarditis  or  that  seen  as  a 
terminal  inflammation  of  nephritis,  etc. 

The  prognosis  is  variable,  the  sero-fibrinous  rheumatic  instances  usually 
going  on  to  recovery  in  two  or  three  weeks;  relapses  may,  however,  occur,  or 
the  condition  pass  on  to  a  chronic  adhesive  pericarditis.  Recovery  from 
septic  and  tuberculous  pericarditis  is  rare. 

Treatment.  The  patient  should  be  at  once  put  to  bed  and  kept  at  rest. 
If  he  is  more  comfortable  in  this  position  his  back  may  be  supported  by 
pillows  or  a  rest.  The  over-action  of  the  heart  should  be  relieved  by  the 
application  of  an  ice  coil  or  bag  to  the  precordium.  In  the  rheumatic  instances 
sodium  salicylate  in  doses  of  i  to  i^  drachms  (4.0  to  6.0),  or  aspirin  45 
grains  (3.0)  daily,  may  be  given  internally.  Usually,  however,  the  inunction 
of  an  ointment  containing  i  part  each  of  salicylic  acid,  oil  of  turpentine  and 
lanolin  to  5  parts  of  simple  ointment  is  to  be  preferred;  of  this  a  drachm  (4.0) 
should  be  thoroughly  rubbed  into  the  precordium  three  times  a  day.  The 
excitabihty  of  the  heart  is  best  relieved  as  above  stated  by  the  applica- 
tion of  cold  in  connection  with  the  administration  of  glyceryl  nitrate 
in  considerable  doses — gr.  -^-^  (0.0012) — three  or  four  times  a  day  in  order 
to  render  the  heart's  work  more  easy  by  lessening  the  peripheral  resistance. 
Venesection  may  be  employed  in  plethoric  individuals  with  the  same  object  in 
view.      These   means  are  preferable  to  the  administration  of  digitalis  and 


554  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

aconite.  If  pain  is  very  seVere  we  may  give  morphine  hypodermatically  with 
atropine — ^  of  a  grain  (0.022)  of  the  former  to  y^-g-  of  a  grain  (0.0006)  of 
the  latter;  these  drugs,  however,  should  not  be  employed  unless  absolutely 
necessary. 

Upon  the  incidence  of  the  effusion  the  above  treatment  should  be  continued 
and  a  good  sized  blister  may  be  applied  to  the  precordium;  not  only  does 
this  act  as  a  counter-irritant  to  the  pain  but  in  some  patients  it  has  a  certain 
effect  in  causing  absorption  of  the  fluid.  If  the  heart  becomes  weak  and  there 
is  venous  stasis,  strychnine  and  digitalis  are  indicated,  or  if  there  is  tendency  to 
syncope  and  collapse,  this  is  to  be  combated  by  the  hypodermatic  injection 
of  caffeine  sodio-benzoate  2  to  5  grains  (0.13  to  0.33)  or  of  camphor  dissolved 
in  sterile  olive  oil  or  aether.  Dyspnoea  due  to  congestion  of  the  lungs  may 
be  relieved  by  strychnine,  which  may  be  given,  if  necessary,  in  doses  as  large 
as  y^^  of  a  grain  (0.006).  Acute  cardiac  dilatation  with  cyanosis  may  be 
treated  in  the  same  fashion.  Throughout  the  course  of  the  affection  the 
bowels  should  be  kept  freely  open  and  the  activity  of  the  kidneys,  which  may 
aid  in  causing  the  disappearance  of  the  effusion,  should  be  insured  by  the 
administration  of  alkaline  diuretics  and  of  the  infusion  of  digitalis  when 
indicated. 

When  the  quantity  of  the  effusion  is  so  large  as  to  interfere  with  the  heart's 
action  as  evidenced  by  marked  dyspnoea  and  cyanosis,  weakness  of  the  pulse, 
an  expression  of  anxiety,  and  coldness  of  the  extremities,  the  pericardium  should 
be  tapped  and  the  pressure  relieved.  An  effusion  large  enough  to  displace 
the  diaphragm  and  the  underlying  viscera  may  also  be  diminished  to  advantage 
by  paracentesis.  Drawing  off  the  fluid  usually  results  in  quick  rehef  of  the 
pressure  symptoms  but  may  not  be  followed  by  quick  recovery.  Several 
tappings  may  be  necessary,  especially  if  the  inflammation  is  tubercvdous.  In 
moderately  large  effusions  the  point  of  puncture  maybe  in  the  fourth  intercostal 
space  about  an  inch  (2.5  c  m.)  to  the  left  of  the  sternal  margin  or  in  the  fifth  space 
i^  inches  from  this  edge.  Dieulafoy  advises  punctiire  in  the  fourth  or  fifth  space 
2  to  2^  inches  from  the  sternum.  Others  advise  the  insertion  of  the  needle 
outside  the  nipple  line.  In  very  large  effusions  a  safe  point  is  in  the  left 
xipho-costal  angle,  the  needle  being  directed  upward  and  backward.  It  is 
unwise  to  draw  off  all  the  fluid  at  once,  6  to  16  ounces  (180.0  to  500.0)  being 
sufficient  for  one  time;  repetition  may  be  necessary  after  a  few  days.  If  the 
fluid  is  purulent  simple  tapping  is  insufficient;  incision  and  drainage  are 
necessary.  It  is  probable  that  recovery  in  pyo-pericarditis  would  be  much 
more  frequent  under  early  surgical  treatment.  It  should  be  needless  to 
state  that  pericardial  puncture  should  be  performed  under  the  strictest 
asepsis. 

The  diet  during  the  acuity  of  the  course  of  a  pericarditis  should  be  of  nour- 
ishing fluids. 


CHRONIC    ADHESIVE    PERICARDITIS.  555 

CHRONIC  ADHESIVE  PERICARDITIS. 

This  condition  often  occurs  in  young  persons  as  a  result  of  a  plastic  peri- 
carditis. Two  forms  are  described:  a.  Simple  adhesion  of  the  peri-  and 
epicardial  layers;  this  often  causes  no  symptoms  and  its  existence  is  unsus- 
pected until  revealed  upon  the  autopsy  table,  h.  Adherent  pericardium 
with  chronic  inflammation  of  the  mediastinum  and  union  of  the  parietal 
layer  of  the  pericardium  to  the  pleura  and  thoracic  wall.  This  type  is  espe- 
cially serious  in  children  and  may  go  on  to  extreme  cardiac  hypertrophy  and 
dilatation. 

Symptoms.  In  type  a  the  symptoms  as  stated  are  unnoticeable;  in  type 
b  they  are  those  of  cardiac  hypertrophy  and  dilatation  with  subsequent 
insufficiency.  With  the  pericardial  adhesions  there  may  proliferative  pleu- 
ritis,  peritonitis,  perihepatitis  and  perisplenitis,  in  a  word  a  panserositis, 
with  which  there  may  be  chronic  ascites. 

Physical  Signs.  Upon  inspection  a  bulging  of  the  precordium  may  be 
noted.  Friedreich's  sign,  a  diastolic  collapse  of  the  cervical  veins  due  to 
their  sudden  emptying  resulting  from  the  expansion  of  the  thorax,  may  be  pres- 
ent. Broadbent's  sign,  a  systolic  tug  communicated  through  the  adherent 
diaphragm,  may  be  noted;  this  is  best  observed  between  the  eleventh  and 
twelfth  ribs  behind  on  the  left  side.  Palpation  reveals  a  diffuse  apical  impulse 
extending  in  marked  instances  from  the  third  to  the  sixth  space  in  a 
vertical  direction  and  laterally  from  the  right  parasternal  line  to  without  the 
left  nipple.  The  apex  beat  may  be  variously  displaced,  is  wavy  in  character 
and  with  the  systole  there  may  be  a  retraction  of  the  thoracic  wall;  the  hand 
may  detect  a  quick  rebound  of  the  wall  of  the  chest,  the  diastolic  shock;  these 
two  latter  are  the  most  typical  signs  of  adherent  pericardium. 

The  pulsus  paradoxus  may  be  present  but  is  not  pathognomonic.  Upon 
percussion  the  cardiac  dulness  is  much  increased.  Adhesions  of  the  peri- 
cardium to  the  pleura  prevent  the  lessening  of  the  cardiac  dulness  upon  deep 
inspiration.  The  signs  elicited  by  auscultation  are  neither  constant  nor  charac- 
teristic. Murmurs  due  to  co-existent  endocardial  lesions  are  often  present 
and  there  may  be  a  modified  pericardial  friction  sound  resembling  the  sound 
caused  by  bending  a  piece  of  new  leather.  A  ventriculo-systolic  murmur 
due  to  a  relative  mitral  insufficiency  or  an  auriculo-systolic  murmur  may  be 
heard.  The  course  of  chronic  adhesive  pericarditis  is  prone  to  be  protracted, 
the  lesion  being  very  likely  to  be  permanent. 

Treatment  consists  in  improving  the  patient's  general  condition  by  the 
administration  of  tonics  and  nourishing  food.  The  symptoms  should  be 
combated  by  appropriate  measures  and  it  may  be  possible  to  facilitate  the 
absorption  of  the  connective  tissue  adhesions  by  the  persistent  inunction 
over  the  cardiac  region  of  a  6  percent,  ointment  of  iodine  vasogen  and  the 


556  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

internal  administration  of  the  syrup  of  hydriodic  acid  in  doses  of  i  drachm 
(4.0)  in  a  wineglass  (60.0)  of  water  one-half  an  hour  before  each  meal. 

OTHER  PERICARDIAL  AFFECTIONS. 

Hydro- pericardium,  an  increase  of  the  normal  amount  of  serous  fluid  con- 
tained in  the  pericardium,  occurs  in  cardiac  or  nephritic  conditions  associated 
with  a  general  anasarca.  The  amount  is  not  often  large  and  the  presence 
of  the  fluid  may  be  overlooked.  Large  transudates  cause  interference  with 
the  action  of  the  heart.  The  physical  signs  are  identical  with  those  of  peri- 
carditis with  effusion. 

Hamo- pericardium.  Blood  is  found  in  the  pericardial  sac  as  a  result  of 
rupture  of  aneurysm  of  the  aorta,  of  the  coronary  arteries,  of  the  heart  itself 
or  of  wounds.  Blood-tinged  fluid  may  be  found  in  the  pericardium  in  tuber- 
culosis or  malignant  growths  of  the  membrane  as  well  as  in  the  pericarditis 
occurring  with  nephritis.  The  physical  signs  are  those  of  any  pericardial 
effusion. 

Pneumo- pericardium  is  rarely  seen  and  is  a  condition  in  which  the  peri- 
cardial sac  contains  gas  and  fluid,  usually  purulent  in  character.  It  is  most 
often  the  result  of  traumatic  or  other  perforation,  from  new  growth,  for  instance. 
In  the  non-perforative  instances  the  growth  of  the  bacillus  cerogenes  may  be  re- 
sponsible. The  symptoms  consist  of  precordial  pain  and  embarrassment  of 
the  heart's  action.  The  physical  signs  are  typical.  The  precordium  may  be 
bulging  and  the  apex  beat  obscured.  The  note  below  is  dull  due  to  the  pres- 
ence of  fluid,  above  it  is  tympanitic.  The  extent  of  these  areas  may  differ 
upon  change  of  the  patient's  position.  Auscultation  reveals  a  heart  sound  of 
metallic,  splashing  or  gurgling  quality.  The  friction  sound  if  present,  is 
also  of  metaUic  quality. 

Calcification  of  the  pericardium  is  rare  but  may  occur  subsequent  to  peri- 
cardial inflammations,  especially  those  of  purulent  or  tuberculous  type.  It 
sometimes  occurs  in  panserositis. 

Treatment  of  the  above  conditions  is  of  little  avail.  If  excessive  fluid 
causes  cardiac  embarrassment  this  may  be  relieved  by  tapping  and  surgical 
measures  may  be  useful  if  external  wound  is  present. 

DISEASES  OF  THE  MYOCARDIUM. 
CARDIAC  HYPERTROPHY. 

Definition.  An  enlargement  of  the  heart  characterized  by  increase  in  the 
thickness  of  the  walls  of  the  organ  and  with  or  without  increase  in  the  size  of  its 
cavities.     When  the  size  of  the  cavities  is  not  augmented  the  condition  is 


CARDIAC    HYPERTROPHY.  557 

termed  simple  hypertrophy;  if  the  enlargement  affects  both  the  thickness  of 
the  walls  and  the  size  of  the  cavities  it  is  spoken  of  as  eccentric  hypertrophy. 
The  enlargement  may  involve  the  entire  heart,  one  side  alone  or  only  one 
cavity. 

.Etiology.  The  condition  is  an  increased  growth  of  muscular  tissue  and 
is  the  result  of  a  physiological  effort  to  perform  increased  work.  The  left 
ventricle  becomes  the  seat  of  hypertrophy  when  there  are  such  interferences 
to  its  action  as  are  furnished  by  obstruction  or  insufficiency  of  the  aortic  valve, 
by  insufficiency  of  the  mitral  valve,  adhesions  of  the  pericardium,  interstitial 
myocarditis,  disorders  of  the  innervation  of  the  organ  followed  by  increased 
cardiac  action  such  as  occur  in  chronic  palpitation,  exophthalmic  goitre,  etc., 
and  in  disturbances  of  the  vascular  system. such  as  arteriosclerosis,  aneurysm, 
contraction  of  the  peripheral  blood-vessels  induced  by  the  presence  of  toxic 
substances  in  the  blood  as  in  nephritis;  hypertrophy  also  occurs  in  muscular 
over-exertion  (the  athlete's  heart)  and  in  congenital  narrowing  of  the  aorta. 

Hypertrophy  of  the  right  ventricle  is  brought  about  by  any  condition  which 
increases  the  resistance  to  the  pulmonary  circulation  such  as  disease  of  the 
mitral  valve;  pulmonary  emphysema  or  fibrosis;  lesions  of  the  valves  of  the 
right  side  of  the  heart,  which  are  often  congenital;  valvular  lesions  of  the 
left  heart  in  the  later  stages  result  in  pulmonary  stasis  and  consequent  obstruc- 
tion to  the  pulmonary  circulation  causing  hypertrophy  of  the  right  ventricle, 
and  adhesions  of  the  pericardium  may  cause  mechanical  interference  with 
its  free  action  and  consequent  hj^ertrophy. 

Hypertrophy  of  the  auricles  is  always  associated  with  dilatation  of  these 
cavities.  The  left  auricle  is  hypertrophied  as  a  result  of  mitral  obstruction 
and  to  a  less  extent  hypertrophy  is  caused  by  the  regurgitation  of  the  blood 
in  mitral  insufficiency.  Hypertrophy  of  the  right  auricle  is  less  likely  to  re- 
result  from  tricuspid  disease  since  here  there  is  much  less  resistance  to  the 
further  backward  flow  into  the  veins  than  upon  the  left  side  of  the  heart. 

Pathology.  The  hypertrophied  heart  is  heavier  and  larger  than  the  nor- 
mal organ  and  its  shape  is  changed.  With  hypertrophy  of  the  left  ventricle 
its  shape  is  less  conical  than  normal,  its  position  is  more  horizontal  and  it 
is  elongated  to  the  left.  Hypertrophy  of  both  ventricles  results  in  a  more 
rounded  shape  and  when  the  h}q3ertrophy  chiefly  involves  the  right  side,  the 
most  bulky  part  of  the  organ  is  the  right  ventricle.  The  walls  of  the  hyper- 
trophied ventricles  are  much  thickened  and  the  muscle  fibres  are  darker  in 
color  and  more  dense  than  normal. 

Symptoms.  Hypertrophy  is  primarily  a  condition  of  physiologic  compensa- 
tion and  at  first  is  unattended  by  symptoms,  but  as  a  result  of  its  continuance 
pathological  changes  take  place  and  connective  tissue  over-growth  occurs 
producing  sclerosis  of  the  arteries  of  the  heart  muscle  and  fibrous  degeneration 
of  the  walls  of  the  organ  and  the  valves.     These  abnormalities  are  evidenced 


558  DISEASES    OF    THE   HEART    AND    BLOOD-VESSELS. 

by  symptoms  which  at  their  inception  are  not  constantly  present  but  are 
induced  by  over-exertion,  mental  or  physical,  over-indulgence  in  stimulants, 
tobacco,  etc.  The  patient  now  complains  of  cardiac  discomfort,  increased 
by  lying  upon  the  left  side,  consciousness  of  the  heart's  action,  palpitation, 
vertigo,  tinnitus,  visual  disorders,  flushing  of  the  face  and  epistaxis. 

Physical  Signs.  Inspection  may  reveal  a  bulging  of  the  precordium, 
especially  in  children,  a  displacement  of  the  apex  beat  downward  and  toward 
the  left  and  a  forcible  and  diffuse  apical  impulse;  there  may  be  visible  pulsa- 
tion of  the  carotids.  Palpation  confirms  the  displacement  and  over-action 
at  the  apex;  the  radial  pulse  is  regular,  full  and  tense.  Percussion  in  hyper- 
trophy of  the  left  ventricle  shows  enlargement  of  the  area  of  cardiac  dulness 
to  the  left  and  downyvard;  of  the  right  ventricle  increased  dulness  to  the  right 
margin  of  the  sternum  and  beyond.  Auscultation  reveals  an  apical  first  sound 
prolonged,  dull  and  perhaps  reduplicated;  the  second  aortic  sound  is  accentuated 
and  it  may  be  reduplicated  in  left  ventricular  hypertrophy,  while  in  right  ven- 
tricular hypertrophy  the  second  pulmonic  sound  is  increased.  A  tinkle  may  be 
audible  at  the  right  of  the  apex  (Boutillau's  sign).  The  apex,  in  hj'pertrophy 
of  the  right  ventricle,  is  displaced  to  the  left  but  not  downward  and  if  there 
is  no  accompanying  left  ventricular  hypertrophy  the  radial  pulse  is  small. 

The  cardiac  shadow,  in  left  ventricular  hypertrophy,  as  shown  by  the 
Rontgen  ray,  is  enlarged,  principally  downward  and  to  the  left ;  in  hypertro- 
phy of  the  right  ventricle  chiefly  to  the  left  and  but  little  downward;  in  extreme 
instances  the  cardiac  shadow  may  be  seen  to  the  right  of  the  sternum. 

The  diagnosis  from  neurotic  palpitation  is  made  upon  the  heaving  character 
of  the  apex  beat,  the  increase  in  cardiac  dulness  and  the  presence  of  accen- 
tuation of  the  second  sounds.  Retraction  of  the  lung  may  uncover  the  heart  so 
that  its  area  of  dulness  is  much  increased  and  hypertrophy  may  be  obscured 
by  the  interposition  of  an  emphysematous  lung.  In  pericardial  effusion 
the  area  of  dulness  is  of  characteristic  triangular  shape,  the  heart  sounds 
are  obscured  and  the  pulse  is  feeble.  In  hypertrophy  with  dilatation  the  pulse 
is  less  strong  and  regular,  murmurs  are  frequently  present  and  there  is  less 
likely  to  be  accentuation  of  the  second  sounds  at  the  base. 

The  prognosis  in  cardiac  hypertrophy  due  to  toxsemia  is  favorable  until 
permanent  arterial  changes  take  place.  When  it  is  the  result  of  arterio- 
sclerosis or  aneurysm  the  prognosis  is  that  of  these  conditions.  H^-pertrophy 
with  chronic  valvular  disease  is  a  conservative  physiological  process  and 
lasts  until  for  some  reason,  over-exertion,  intercurrent  illness,  malnutrition 
etc.,  dilatation  supervenes. 

Treatment.  So  long  as  no  symptoms  are  present  this  consists  in  main- 
taining the  patient's  nutrition,  avoiding  over-exertion  and  indulgence  in 
alcohol,  tobacco,  tea  and  coffee  and  in  obtaining  sufficient  sleep.  Simple 
tonics  may  be  prescribed  if  indicated.     If  arteriosclerosis  is  present  we  may 


CAEDIAC    DILATATION.  559 

administer  the  iodides,  preferably  in  the  form  of  the  syrup  of  hydriodic  acid,  i 
drachm  (4.0)  in  a  wineglass  (60.0)  of  .water  a  half  hoiir  before  each  meal.  For 
the  cardiac  distress  the  fiuidextract  of  cactus  in  doses  of  10  to  20  minims 
(0.66  to  1.33)  three  times  daily  may  be  given.  If  the  palpitation  is  annoying 
the  following  prescription  may  be  found  beneficial:  I^  potassii  bromidi,  potassii 
iodidi,  aa  gr.  Ixxv  (5.0);  sjTupi  aurantii  §  vi  (180.0).  Misce  et  signa,  two  tea- 
spoonsful  (8.0)  night  and  morning.  If  the  heart  is  laboring  against  excessive 
arterial  tension  we  may  give  glyceryl  nitrate  gr.  j}-^  to  5V  (0.0006  to  0.0012) 
or  erythrol  tetranitrate  gr.  i  to  J  (0.016  to  0.032)  made  up  in  pill  form  with 
kaolin,  three  times  a  day. 

CARDIAC  DILATATION. 

.etiology.  Acute  cardiac  dilatation  of  transitory  type  may  occur  as  a 
result  of  pronounced  muscular  over-exertion.  Chronic  dilatation  is  associated 
with  hypertrophy  and  is  due  either  to  an  increase  of  the  endocardial  pressure  re- 
sulting in  over-filling  of  the  chambers  or  to  an  obstruction  to  the  outflow  of  blood 
caused  by  valvular  or  vascular  lesions.  These  causes  may  not  at  once  lead 
to  dilatation  but  often  first  result  in  hypertrophy,  the  latter  being  always  to 
some  extent  present  except  in  instances  of  very  acute  dilatation.  In  eccentric 
hypertrophy  dilatation  is  a  process  of  physiological  compensation,  going  on 
until  failure  of  the  nutrition  of  the  heart  supervenes  when  immediately  the  dila- 
tation exceeds  the  hypertrophy  to  a  marked  extent  (failure  of  compensation). 
This  condition  may  result  in  endocarditis,  the  infectious  diseases,  chronic 
wasting  diseases,  and  prolonged  mental  or  physical  over-exertion.  Acute 
dilatation  may  result  from  sudden  excessive  muscular  effort  as  in  mountain 
climbing,  rowing,  bicycling,  etc.  Exercise  within  proper  limits  produces 
hypertrophy  with  dilatation,  not  simple  dilatation,  i.e.,  enlargement  of  the 
cavity  with  compensatory  thickening  of  its  walls.  The  harmful  effect  of  pro- 
longed cardiac  strain  is  held  in  check  temporarily  by  the  action  of  the  tricuspid 
valve  in  allowing  a  regurgitation  of  blood  into  the  right  auricle,  but  physiolog- 
ical dilatation  has  passed  beyond  its  limit  when  the  cavity  has  become  unable 
to  empty  itself  of  blood.  Here,  although  the  reserve  capacity  of  the  heart 
has  been  exceeded,  the  normal  condition  may  be  restored  by  rest. 

A  second  factor  which  may  result  in  cardiac  dilatation  is  a  decreased  resis- 
tance of  the  cardiac  walls;  these  may  be  weakened  by  fatty  and  fibrous  degen- 
eration, the  degeneration  which  takes  place  during  the  acute  infectious  diseases, 
in  endocarditis  and  pericarditis,  in  disturbances  of  nutrition  and  in  chronic 
blood  diseases.     Idiopathic  dilatation  may  occur. 

Pathology.  Dilatation  involves  the  right  heart  more  often  than  the  left 
and  at  least  two  chambers  are  usually  affected;  it  is  generally  secondary  to 
valvular  defects  and  is,  in  most  instances,  associated  with  hypertrophy.     Ex- 


560  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

treme  dilatation  produces  a  relative  insufficiency  of  the  valves,  these,  although 
being  of  normal  size  and  condition,  are  npt  able  to  close  their  respective  orifices 
on  account  of  the  great  expansion  of  the  valvular  ring  consequent  upon  the 
dilatation  or  from  the  fact  that  the  enlargement  of  the  cardiac  chambers  so 
draws  upon  the  papillary  muscles  that  these  are  insufficiently  long  to  allow  the 
valve  flaps  to  fall  into  place.  The  shape  of  the  organ  is  changed  depending 
upon  the  situation  and  extent  of  the  dilatation;  when  this  involves  the  whole 
heart  its  shape  becomes  somewhat  spherical.  The  endocardium  may  be 
opaque  and  roughened;  the  myocardium  is  usually  the  seat  of  a  fatty,  fibrous 
or  parenchymatous  degeneration;  degeneration  of  the  cardiac  ganglia  has 
been  observed. 

Symptoms.  Sudden  acute  dilatation  is  evidenced  by  cardiac  or  epigastric 
distress  or  pain,  sudden  dyspnoea,  rapid  and  feeble  heart  action  and  signs  of 
venous  obstruction.  In  very  acute  instances  sudden  death  without  symptoms 
may  take  place.  In  the  milder  forms  of  the  affection  the  patient  suffers  from 
palpitation,  dyspnoea,  faintness  and  feeble  cardiac  action;  all  these  are  much 
relieved  by  rest,  but  return  upon  the  least  exertion. 

In  dilatation  with  compensatory  hypertrophy  there  are  no  subjective  symp- 
toms but  immediately  upon  the  disturbance  of  the  compensation  the  signs 
of  venous  congestion  are  developed,  dyspnoea,  oedema,  beginning  in  the  feet 
and  extending  upward,  rapid,  feeble  and  irregular  heart  action,  cough,  diges- 
tive disturbances,  dizziness  and  headache  and  even  delirium  and  coma;  rarely 
is  the  pulse  rate  slow.  Palpitation  and  symptoms  resembling  those  of  angina 
pectoris  may  occur.  The  urine  is  dark,  of  high  specific  gravity,  scanty  and 
may  contain  hyaline  casts  and  red  blood  cells. 

Physical  Signs.  Upon  inspection  the  apical  impulse  is  seen  to  be  weak, 
irregular  and  diffused  over  a  considerable  area,  there  may  be  no  point  of 
maximum  intensity  or  this  may  beabove  and  to  the  left  of  the  normal  position. 
When  the  hypertrophy  chiefly  affects  the  right  side  of  the  heart  the  apex  im- 
pulse is  absent  but  an  impulse  may  be  palpable  below  or  to  the  right  of  the 
xiphoid  cartilage  and  there  may  be  a  diffuse  wave  in  the  fourth,  fifth  and 
sixth  left  spaces.  There  may  be  a  visible  pulsation,  usually  synchronous  with 
the  systole,  less  frequently  presystolic,  in  the  second  left  space.  When  there 
is  dilatation  of  the  right  auricle  a  systolic  impulse  may  be  detected  in  the  third 
right  space.  Percussion  reveals  increased  dulness  to  the  right  or  left  and 
downward,  unless  the  enlarged  heart  is  overlapped  by  emphysematous  pul- 
monary tissue.  Upon  anscidtalion  various  sounds  due  to  complications  may 
be  audible.  The  characteristic  signs  are  present  only  in  the  idiopathic  type 
of  dilatation;  these  are  a  weak  but  not  impure  first  sound;  at  times  it  may  be 
almost  inaudible  or  reduplicated  as  a  result  of  lack  of  synchronous  contrac- 
tion of  the  right  and  left  sides  of  the  heart  and  the  loud  ventriculo-systolic 
murmur  of  a  relative  mitral  insufficiency  may  be  present.     The  second  pul- 


CARDIAC    DILATATION.  56 1 

monic  sound  is  distinct  if  only  dilatation  of  the  left  ventricle  with  hypertrophy 
of  the  right  is  present.  It  is  weak  if  the  dilatation  affects  the  right  ventricle. 
The  heart  action  is  irregular,  w^ak  and  intermittent.  A  gallop  rhythm  is  typi- 
cal of  dilatation  but  is  not  constantly  present. 

The  diagnosis  in  differentiation  from  pericardial  effusion  (see  p.  553)  may 
be  difficult ;  from  hypertrophy,  dilatation  may  be  distinguished  by  the  indefi- 
nite, diffuse  and  undulatory  apex  impulse,  by  the  weakness  and  irregularity 
of  the  pulse  and  the  lack  of  accentuation  of  the  second  sounds  at  the  base. 

The  prognosis,  while  unfavorable  as  to  final  result,  should  be  guarded;  proper 
treatment  often  succeeds  to  a  considerable  extent  in  relieving  symptoms  and 
prolonging  life. 

Treatment.  The  chief  essential  is  complete  rest  in  bed;  under  this  alone 
temporary  recovery  may  be  brought  about  in  many  instances.  Cardiac 
stimulants  should  be  prescribed  as  in  valvular  disease  with  failing  compen- 
sation (see  p.  591).  In  the  acute  type  of  dilatation,  venesection  may  greatly 
relieve  the  failing  heart,  especially  if  failure  of  the  right  heart  is  present  as 
evidenced  by  dyspnoea  and  cyanosis. 

The  employment  of  the  so-called  Nauheim  baths  and  after  the  acute  symp- 
toms have  disappeared,  of  the  exercises  originated  by  the  Schott  brothers 
and  modified  by  the  resistance  movements  of  the  Lingg  Swedish  system  of 
exercises,  is  often  fraught  with  excellent  results.  In  connection  with  these 
the  patient's  mode  of  life  and  diet  should  be  regulated  according  to  the  strictest 
principles  and  no  measure  calculated  to  prevent  a  recurrence  of  the  dilatation 
should  be  omitted. 

The  Nauheim  treatment  is,  of  course,  most  effectual  when  undertaken  at 
the  springs  but  artificial  imitations  of  the  natural  baths  may  be  taken  at  home 
and  from  these  excellent  results  may  be  obtained.  Artificial  Nauheim  salts 
are  now  supplied  by  the  manufacturing  chemists  or  may  be  made  up  by  any 
pharmacist,  the  formula  being  supplied  by  the  physician.  They  depend 
chiefly  for  their  action  upon  the  evolution  of  carbonic  acid  gas  and  may  be 
employed  in  various   strengths. 

Bath  No.  I.     Sodium  chloride  4  lbs.  (2,000);  calcium  chloride  6  oz.  (180). 

Bath  No.  2.     Sodium  chloride  5  lbs.  (2,500);  calcium  chloride  8  oz.  (240). 

Bath  No.  3.     Sodium  chloride  6  lbs.  (3,000);  calcium  chloride  10  oz.  (300). 

Bath  No.  4.  Sodium  chloride  7  lbs.  (3,500);  calcium  chloride  10  oz.  (300); 
sodium  bicarbonate  ^  lb.  (250);  25  percent,  hydrochloric  acid  12  oz.  (360). 

Bath  No.  5.  Sodium  chloride  9  lbs.  (4,500);  calcium  chloride  11  oz.  (330); 
sodium  bicarbonate  i  lb.  (500);  25  percent,  hydrochloric  acid  i^  lbs.  (750). 

Bath  No.  6.  Sodium  chloride  10  lbs.  (5,000);  calcium  chloride  12  oz.  (360); 
sodium  bicarbonate  2  lbs.  (1,000);  25  percent,  hydrochloric  acid  3  lbs.  (1,500). 
The  amounts  given  are  suitable  for  a  bath  of  40  gallons  (160  litres). 

A  porcelain  tub  should  be  used  or  the  salts  should  be  dissolved  in  earthen 
36 


562  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

bowls  if  the  tub  is  of  metal.  When  the  salts  have  been  dissolved  the  bottle 
containing  the  hydrochloric  acid  is  inverted  and,  with  its  mouth  below  the 
surface  of  the  water,  the  stopper  is  removed  and  the  acid  uniformly  mixed  with 
the  bath.  The  patient  should  now  get  in  at  once  so  as  to  get  the  full  benefit 
of  the  evolution  of  the  carbonic  acid  gas.  The  numbers  5  and  6  are  seldom 
prescribed. 

In  addition  to  the  carbonic  acid  other  beneficial  factors  possessed  by  the 
natural  Nauheim  baths  are  the  warmth  and  the  fact  that  it  is  natural  warmth; 
the  presence  of  alkaline  salts  and  of  metals  in  large  quantities;  the  coincident 
combination  of  the  carbonic  acid  gas  with  the  salts  and  other  elements,  and  a 
certain  amount  of  electro-magnetism  which  the  waters  are  considered  to  hold. 

The  temperature  of  the  bath  at  the  beginning  should  be  from  92.3°  to  95°  F. 
(33.5°  to  35°  C.)  according  to  the  condition  of  the  patient,  considering  whether 
he  is  stout  or  lean,  young  or  old  and  whether  he  is  accustomed  to  cool  or  warm 
bathing.  The  temperature  may  be  gradually  lowered  4  to  6  degrees  F. 
(2  to  4  degrees  C.)  but  in  most  instances  rather  less  than  these  figures;  with 
some  patients  a  constant  temperature  is  maintained  for  the  greater  part  of 
the  time. 

The  patient  remains  in  the  bath  at  first  from  4  to  6  minutes;  gradually 
this  time  is  increased  to  10  or  12  minutes,  exceptionally  to  15  or  20.  Upon 
changing  the  bath  for  a  stronger,  the  initial  duration  should  be  lessened  and 
the  maximum  time  depends  upon  the  patient's  condition  and  his  reaction 
to  the  measure.  The  guide  to  the  proper  length  of  a  bath,  after  the  first  few 
have  been  taken,  is  a  change  of  pulse  from  a  slower  and  fuller  to  a  more  rapid 
and  smaller  one  or  when  other  signs  of  weakness  are  noticed.  After  the  bath 
the  patient  should  be  dried  with  a  warm  towel  and  during  the  process  or  shortly 
afterward  he  should  take  a  little  simple  solid  or  liquid  food,  he  should  then  rest 
for  about  a  half  hour,  during  which  he  may  doze  but  should  not  slumber  deeply 
for  this  latter  causes  a  relaxation,  during  which  much  of  the  tonic  effect  of 
the  bath  is  lost. 

The  baths  produce  the  most  benefit  when  given  on  alternate  days  and  should 
never  be  given  upon  two  successive  days  without  an  omission  upon  the  third. 
In  rare  instances  two  day  rests  may  be  necessary.  The  strength  of  the  baths 
may  be  gradually  increased  and  their  temperature  slightly  lowered,  never, 
however,  below  82°  F.  (27°  C.)  and  seldom  to  this  point. 

The  number  of  baths  necessary  to  complete  a  treatment  varies;  usually 
we  anticipate  a  good  result  from  twenty  to  twenty-five;  often  it  is  well  to  stop  the 
baths  when  this  number  has  been  reached  and  if  the  desired  effect  has  not  been 
attained  to  advise  a  change  of  air  for  a  month,  the  bathing  to  be  resumed 
at  the  end  of  this  period. 

The  physiological  effect  of  the  baths  results  in  a  slowing  of  the  pulse  rate 
and  an  increase  in  its  force  and  a  lessening  of  the  dyspnoea,  after  the  first  few 


CARDIAC    DILATATION.  563 

moments;  in  some  instances  internal  congestion  is  so  much  relieved  that  in 
thin  subjects  the  area  of  cardiac  dulness  is  diminished  showing  that  the  heart  has 
contracted  as  a  result  of  the  greater  ease  with  which  it  performs  its  function; 
the  size  of  the  liver  is  said  also  to  diminish  and  the  amount  of  haemoglobin 
and  number  of  red  blood  cells  to  become  increased. 

Before  beginning  the  exercises  we  should  attain  positive  benefit  from  the 
baths  and  the  employment  of  massage  is  advisable  before  commencing  the 
exercises  proper.  This  massage  should  consist  of  a  stroking  of  the  limbs 
from  the  extremities  upward;  abdominal  massage  should  be  performed  with 
the  greatest  care  since  it  may  cause  cardiac  depression.  These  strokings 
may  be  continued  at  first  for  5  or  10  minutes,  later  for  20  minutes  and  should 
be  followed  by  a  period  of  rest.  Respiratory  exercises,  in  the  open  air,  if 
possible,  if  not  in  a  thoroughly  ventilated  apartment,  are  very  useful.  The 
patient  places  a  cane  behind  his  shoulders  and  in  front  of  his  upper  arms 
and  walks  about  taking  regular  and  deep  breaths.  After  the  latter  and  the 
massage  have  been  continued  for  two  or  three  weeks  the  exercises  may  be 
instituted  under  the  following  rules:  The  patient  should  not  hold  the  breath 
but  should  breathe  with  regularity;  exercises  which  cause  an  intermittent 
heart  action  must  be  omitted;  only  moderate  resistance  should  be  employed 
at  first;  no  movements  should  be  used  which  bring  the  hands  above  the  level 
of  the  shoulders,  for  raising  the  hands  increases  arterial  tension  and  weakness, 
and  retards  the  heart  action.  The  exercises  include  all  ordinary  movements 
of  the  limbs  and  extremities;  these  are  made  by  the  patient  against  the  moder- 
ate resistance  of  the  attendant.  Lateral  and  rotatory  movements  of  the  body 
are  included.     They  should  never  be  continued  until  the  patient  is  tired. 

In  fatty  heart,  after  a  course  of  the  above  treatment  which  has  benefited 
the  patient  to  a  sufficient  degree,  hill  and  stair  climbing  in  moderation  may  be 
prescribed.  The  walk  should  at  first  be  short  and  up  only  a  moderate  incline 
stopping  every  10  or  15  yards  to  rest  and  to  take  several  full  breaths.  If 
the  respiration  becomes  hurried  under  this  exercise  it  should  be  omitted;  if 
no  untoward  symptoms  are  induced  the  walks  may  be  gradually  lengthened 
to  from  100  feet  to  five  or  ten  times  this  distance.  Stair  climbing,  resting 
for  a  few  breaths  every  four  or  five  stepS;  may  be  substituted  in  unpleasant 
weather. 

With  regard  to  diet  we  can  lay  dov^ni  no  fixed  rvdes.  Alcohol  should  be 
interdicted  except  in  old  persons  who  have  become  accustomed  to  its  use. 
Beer  should  not  be  allowed  even  here,  but  we  may  permit  a  little  whiskey 
or  wine  with  the  noon  and  evening  meals.  Coffee  is  best  omitted  but  if  tea 
and  cocoa  are  unpalatable  a  little  very  weak  coffee  may  be  taken  at  breakfast. 
Milk  is  by  far  the  drink  to  be  preferred,  and  in  arteriosclerosis  should  comprise 
the  chief  part  of  the  diet.  Starches  should  be  avoided  here  but  eggs  may  be 
allowed.     With  a  fatty  heart  fats  should  be  forbidden  and  starches  as  well; 


564  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

lean  meat,  fish  and  green  vegetables  may  be  allowed.     Liquids  with  meals 
are  not  permissible  but  may  be  taken  in  the  intervals. 

Contra-indications  to  the  Schott  or  Nauheim  treatment  are  chronic  nephritis, 
advanced  aneurysm  and  arteriosclerosis  in  its  late  stages.  All  patients  who 
are  afflicted  with  this  stage  even  in  its  incipiency  must  be  most  carefully 
watched  while  undergoing  this  treatment  for  often  albuminuria  and  casts 
in  the  urine  appear  which  seem  to  be  caused  by  the  baths;  these  in  many 
instances  may  yet  be  continued  with  benefit  to  the  patient  but,  as  stated  above 
the  greatest  watchfulness  upon  the  part  of -the  physician  is  necessary. 

CARDIAC  ATROPHY. 

This  condition  consists  in  a  diminution  in  the  muscular  substance  of  the 
cardiac  walls  and  a  consequent  contraction  in  the  size  of  the  chambers  of  the 
organ.  It  occurs  with  the  chronic  wasting  diseases,  especially  tuberculosis 
and  cancer;  it  is  also  observed  in  senile  marasmus  and  occasionally  in  chronic 
endocarditis.  The  reduction  in  size  of  the  organ  is  usually  symmetrical. 
Its  color  is  dark  brown  and  its  walls  are  firm  in  consistence.  Under  the 
microscope,  granules  of  a  brown  pigment  are  seen  about  the  nuclei  of  the 
muscle  cells  and  between  the  fibrillfe. 

The  condition  causes  no  special  symptoms,  only  those  of  the  causal  disease 
being  present,  the  pulse  is  weak  and  the  physical  signs  consist  of  a  reduction 
in  the  normal  area  of  cardiac  dulness,  weakness  of  the  apex  impulse  and  of 
the  heart  sounds.  In  pulmonary  emphysema  the  lung  may  overlap  the  heart 
so  as  to  diminish  its  area  of  dulness,  consequently  this  condition  is  to  be 
excluded  in  the  diagnosis  of  cardiac  atrophy. 

Treatment  consists  in  the  employment  of  the  approved  measures  calculated 
to  benefit  the  causal  affection. 

MYOCARDITIS. 
Parenchymatous  Myocarditis. 

Synonym.     Parenchymatous  or   Albuminoid  Degeneration  of  the   Heart. 

This  condition  consists  of  a  conversion  of  the  normal  muscular  substance 
of  the  cardiac  wall  into  a  granular  albuminoid  matter  soluble  in  acetic  acid 
but  not  in  aether.  Microscopically  the  striae  of  the  muscle  fibres  are  indistinct 
or  invisible;  on  gross  inspection  the  heart  muscle  is  pale  and  in  consistency 
it  is  very  soft.  Parenchymatous  degeneration  is  believed  to  be  the  result  of 
some  toxic  influence  and  is  met  in  the  acute  infectious  diseases  such  as  small- 
pox, enteric  fever,  scarlatina,  etc.  It  is  no  longer  considered  to  be  due  to 
prolonged  high  temperature  and  is  not  a  permanent  change. 


FATTY    MYOCARDITIS.  565 

Fatty  Myocarditis. 

Synonym.     Fatty  Degeneration  of  the  Heart. 

Definition.  A  degeneration  of  the  heart  muscle  characterized  by  the 
replacement  of  the  normal  tissue  by  fat. 

^Etiology.  Fatty  myocarditis  occurs  as  a  result  of  prolonged  acute  infec- 
tions, in  the  chronic  wasting  diseases,  especially  pernicious  anaemia,  as  a 
senile  change,  in  phosphorus  and  arsenic  poisoning,  in  pericarditis  and 
with  sclerosis  of  the  coronary  arteries.  The  hypertrophied  and  dilated  heart 
of  chronic  endocarditis  may  undergo  fatty  degeneration. 

Pathology.  The  replacement  of  normal  muscle  by  fat  may  be  localized 
in  one  part  of  the  organ  or  generalized;  most  frequently  it  affects  the  left 
ventricle.  In  the  former  instance  there  may  be  small  foci  of  fat  in  the  muscle 
immediately  underlying  the  pericardium;  these  may  occur  only  in  the  layers 
subjacent  to  the  myocardium  or,  as  a  result  of  thrombosis  or  embolism  of  a 
branch  of  the  coronary  artery  an  isolated  focus  of  fatty  metamorphosis  may 
be  found  in  the  wall  of  the  left  ventricle  or  in  the  inter- ventricular  septum; 
this  at  first  is  haemorrhagic  or  brownish  and  later  becomes  white  and  is  known 
as  a  white  infarct  or  an  area  of  anaemic  necrosis.  This  may  finally  disintegrate 
and  be  replaced  by  caseous  matter  or,  weakening  the  cardiac  wall,  may  result  in 
rupture.  General  fatty  myocarditis  is  evidenced  by  a  dilatation  of  the  organ; 
it  is  soft  and  flabby,  light  yellowish-brown  in  color  and  little  force  suffices 
to  tear  its  walls;  there  may  be  deposits  of  fat  in  the  papillary  muscles.  Under 
the  microscope,  fat  droplets  are  seen  along  the  margins  of  the  muscle  fibres; 
in  marked  instances  the  fat  may  almost  entirely  replace  the  muscular  tissue. 
With  the  fatty  degeneration  of  the  myocardium  there  may  be  a  similar  condi- 
tion in  the  solid  viscera  and  in  the  muscular  fibres  of  the  diaphragm. 

Symptoms.  These  may  be  nil  so  long  as  dilatation  does  not  supervene, 
and  upon  the  incidence  of  this  complication  it  is  responsible,  rather  than  the 
fatty  change  in  the  heart  wall,  for  the  clinical  manifestations  which  occur. 
These  are  those  of  dilatation  occurring  from  any  cause — dyspnoea,  palpita- 
tion, irregular  and  feeble  heart  action,  etc. 

The  prognosis  of  the  condition  is  unfavorable,  no  therapeutic  measures  being 
able  to  influence  the  pathological  condition  which  is  permanent. 

Treatment.  This  is  identical  with  that  of  cardiac  dilatation — rest  in  bed 
and  stimulation  for  the  acute  attacks  and  later,  or  before  these  appear,  if  the 
diagnosis  is  made  so  soon,  the  Nauheim  or  Schott  method  (see  p.  561)  is  indi- 
cated. 

Fatty  Infiltration  of  the  Heart. 

Synonyms.     Fatty  Over-grovi1:h;  Cor  Adiposum. 

This  condition  consists  in  an  increase  of  the  normal  sub-pericardial  fat  but 


566  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

finally  the  myocardium  may  be  involved,  the  fat  making  its  way  between  the 
muscular  fibres  of  the  heart  wall  even  as  far  as  its  endocardial  lining.  It 
is  usually  associated  with  obesity  and  is  a  disease  occurring  in  late  middle 
life  and  affecting  males  more  than  females.  The  fatty  change  ultimately 
interferes  with  the  nutrition  of  the  organ  and  impairs  its  action.  Here  the 
symptoms  are  those  of  true  fatty  myocarditis.  In  the  earlier  stages  the 
symptoms  are  those  of  cardiac  insufficiency  associated  with  obesity. 
The  treatment  is  that  of  obesity  and  fatty  myocarditis. 

Amyloid  degeneration  of  the  heart  has  been  observed.  The  patholog- 
ical change  involves  the  walls  of  the  blood-vessels  and  the  inter-muscular 
connective  tissue. 

Hyaline  degeneration  (Zenker)  affects  the  muscle  fibres,  rendering  them 
swollen  and  transparent  and  partially  or  wholly  obliterating  their  striae. 

Calcareous  degeneration  occurs  rarely,  being  characterized  by  an  infil- 
tration of  the  muscular  tissue  with  calcium  salts. 

Fibrous  Myocarditis. 

Synonyms.  Fibro-myocarditis;  Interstitial  Myocarditis;  Fibroid  Heart; 
Coronary  Arteriosclerosis. 

Definition.  A  condition  in  which  the  normal  muscular  tissue  of  the  heart 
is  to  a  greater  or  less  extent  replaced  by  fibrous  tissue. 

^Etiology  and  Pathology.  Fibrous  degeneration  of  the  heart  wall  is  the 
result  of  sclerosis  of  the  coronary  arteries,  consequently  the  causes  of  fibro- 
myocarditis  are  those  of  coronary  arteriosclerosis  and  these  are  those  of  endar- 
teritis in  general  (see  p.  606).  Disease  of  the  coronary  arteries  diminishes 
the  blood  supply  of  the  heart  muscle  which  resuhs  in  a  gradual  degeneration 
of  the  muscular  fibres  which  are  finally  replaced  by  sclerotic  tissue.  This 
change  is  most  frequently  observed  in  the  wall  of  the  left  ventricle  near  the 
apex  or  in  the  septum,  but  may  take  place  in  any  part  of  the  cardiac  muscle. 

Disease  of  the  coronary  arteries  also  leads  to  the  occurrence  of  areas  of 
anaemic  necrosis  in  the  heart  wall  as  a  result  of  thrombosis  or  embolism. 
These  areas  are  yellowish  in  color,  may  be  conical  in  shape  and  may  project 
beyond  the  surface  of  the  organ.  They  at  first  soften  and  become  degenerated, 
later  they  undergo  sclerotic  or  hyaline  changes. 

With  the  fibrous  degeneration  of  the  heart  muscle  valvular  lesions  may 
co-exist  which  may  be  a  factor  in  the  production  of  the  fibrosis  because  of  the 
resulting  venous  congestion,  or  emboli  from  the  valves  may  find  their  way  into 
the  coronary  arteries  and  cause  anaemic  infarcts.  The  lodgment  of  infective 
emboli  from  any  source,  in  the  coronary  arteries  gives  rise  to  septic  infarctions 


FIBROUS    MYOCARDITIS.  567 

which  become  abscesses  of  varying  size.  Small  ones  may  give  no  symptoms 
but  larger  ones  may  either  perforate  internally  or  outwardly  into  the  peri- 
cardium— the  so-called  acute  cardiac  ulcer. 

Symptoms.  In  the  mild  degrees  of  fibrosis  there  may  be  no  symptoms 
and  the  disease  may  be  of  such  degree  as  to  cause  sudden  death  in  a  subject 
who  has  never  considered  his  heart  diseased.  The  association  of  endo- 
carditis with  myocarditis  may  obscure  the  symptoms  of  the  latter.  When 
occurring  independently  fibro-myocarditis  is  evidenced  by  the  ordinary  symp- 
toms of  cardiac  dilatation  (see  p.  547),  dyspnoea,  palpitation,  rapid  or  con- 
stantly slow  pulse,  arrhythmia  and  often  Cheyne-Stokes  respiration  at  night. 
Late  manifestations  are  those  referable  to  general  venous  congestion  such  as 
oedema,  cyanosis,  etc.  Anginoid  attacks  may  occur  and  marked  mental 
symptoms,  due  to  circulatory  changes  in  the  brain,  may  be  observed. 

Physical  Signs.  The  apex  impulse  is  usually  weak  and  may  be  found 
with  great  difficulty,  unless  dilatation  is  present,  when  its  area  is  diffuse;  the 
area  of  cardiac  dulness  is  diminished  in  size.  The  quality  of  the  first  sound  at 
the  apex  is  less  clear  than  normal  and  in  the  later  stages  both  first  and  second 
sounds  become  diminished  in  intensity.  A  ventriculo-systolic  murmiur  may 
be  present  at  the  apex,  this  murmur  is  less  constant  than  that  of  mitral  insuffi- 
ciency and  is  not  accompanied  by  an  accentuation  of  the  pulmonic  second  sound, 
which  latter  may  be  reduplicated. 

The  diagnosis  is  not  easy;  the  frequent  presence  of  associated  valvular 
lesions  does  not  tend  to  simplify  matters;  when  we  find  a  manifestly  diseased 
heart,  in  which  no  murmurs  are  heard  and  general  arteriosclerosis  is  present, 
in  a  subject  beyond  middle  life,  we  are  usually  safe  in  diagnosticating  fibrous 
myocardial  degeneration. 

The  prognosis  is  unfavorable  yet  life  may  be  sustained  for  long  periods 
and  in  comparative  comfort;  the  accompanying  disease  of  the  coronary  arteries, 
however,  renders  sudden  death,  due  to  blocking  of  these,  possible  at  any 
time. 

Treatment.  An  endeavor  to  promote  the  absorption,  or  at  least  to  prevent 
the  further  production  of  fibrous  tissue  in  the  walls  of  the  coronary  arteries- 
may  be  made  by  administering  iodine.  The  syrup  of  hydriodic  acid — 5i  (4-o) 
in  a  wine  glass  of  water  one-half  an  hour  before  meals — or  potassium  iodide, 
the  latter  having  a  vaso-dilator  action,  may  be  employed.  The  patient's 
mode  of  life  should  be  regulated  just  as  in  the  treatment  of  arteriosclerosis 
(see  p.  595),  alcohol  and  tobacco  should  be  forbidden  and  over-eating  and 
over- work  avoided.  The  vessels  may  be  kept  open  if  tension  is  present, 
and  the  tendency  to  heart  weakness  and  venous  congestion  combated  by  the 
same  means  as  those  mentioned  under  the  treatment  of  cardiac  dilatation. 
Rest  in  bed  is  often  a  very  necessary  adjunct  to  treatment.  Digitalis  should 
not  be  prescribed  for  patients  who  have  a  constantly  slow  pulse  and  an  increased 


568  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

vascular  tension.  The  treatment  by  means  of  Nauheim  baths,  massage  and 
resistance  exercises  (see  p.  561)  in  properly  selected'  patients  will  prove  of 
great  benefit. 

ACUTE  SUPPURATIVE  MYOCARDITIS. 

Synonym.     Cardiac  Abscess. 

In  pyosmic  states  infective  emboli  may  lodge  in  the  branches  of  the  coronary 
arteries,  as  previously  stated,  and  cause  abscesses.  These  may  be  very  tiny, 
in  which  case  they  usually  cause  no  symptoms,  or  of  larger  size;  in  the  latter 
instance  they  may  rupture  into  one  of  the  chambers  of  the  heart  or  externally 
into  the  pericardial  sac.  In  the  former  case  the  blood  current  takes  up  the 
infectious  matter  and  scatters  it  through  the  body  to  cause  other  embolic 
abscesses;  in  the  latter  suppurative  pericarditis  and  death  result. 

ANEURYSM  OF  THE  HEART. 

Cardiac  Aneurysm  occurs  in  two  forms: 

a.  Valvular  aneurysm  which  may  take  place  in  acute  endocarditis  as  a 
result  of  weakening  of  a  localized  area  in  one  of  the  valvular  segments  through 
ulceration.  Rupture  may  take  place  through  the  weakened  area  or  the  pres- 
sure of  the  blood  may  cause  an  aneurysmal  dilatation  upon  the  ventricular 
surface  of  the  flap.  Rupture  of  such  an  aneurysm  results  in  insufficiency 
of  the  affected  valve.     The  aortic  is  the  valve  most  often  affected. 

h.  Aneurysm  oj  the  cardiac  wall  may  be  caused  by  injury  or  occur  as  a 
result  of  weakening  due  to  myocardial  degeneration.  Its  most  frequent 
site  is  in  the  wall  of  the  left  ventricle  near  the  apex.  The  weakened  wall 
bulges  and  the  resulting  dilatation  varies  in  size  from  that  of  a  good  sized  pea 
to  that  of  the  heart  itself.  Succulation  and  multiple  aneurysms  have  been 
observed.     Rupture  into  the  pericardium  may  take  place. 

The  symptoms  are  not  definite  and  the  condition  is  not  likely  to  be  diag- 
nosticated with  any  certainty  during  life. 

RUPTURE  OF  THE  HEART. 

Rupture  of  the  cardiac  wall  may  take  place  as  a  result  of  almost  any  disease 
of  this  structure  but  is  most  frequent  in  fatty  myocarditis  with  white  infarct. 
It  has  also  been  observed  in  fibrous  degeneration  of  the  heart  muscle,  abscess, 
malignant  neoplasm  and  gumma.  It  is  most  common  in  the  aged  but  has 
been  noted  in  infants;  it  is  usually  induced  by  over-exertion  but  may  take 
place  spontaneously  and  without  symptoms  of  warning.  The  favorite  site 
of  the  rupture  is  the  anterior  wall  of  the  left  ventricle  near  the  septum. 


ACUTE    ENDOCARDITIS.  569 

Death  from  rupture  may  take  place  immediately  or,  exceptionally,  life  may 
be  prolonged  for  a  few  hours.  In  this  case  the  patient  suffers  from  oppression, 
dyspnoea,  cardiac  pain  and  collapse.  Physical  examination  should  reveal 
the  signs  of  a  pericardium  distended  with  fluid. 

DISEASES  OF  THE  ENDOCARDIUM. 
ACUTE  ENDOCARDITIS. 

Definition.  An  acute  inflammation  of  the  membrane  lining  the  heart,, 
usually  confined  to  that  portion  which  covers  the  valves,  and  characterized 
by  the  development  upon  these  structures  of  vegetations  with  loss  of  valvular 
substance.  It  is  often  and  properly  termed  valvulitis.  In  rare  instances  the 
lining  of  the  heart's  chambers  may  be  involved. 

Acute  endocarditis  occurs  in  two  main  t>^es,  the  mild  or  simple  and  the 
malignant,  infective  or  mycotic;  there  is,  however,  no  distinct  line  of  demar- 
cation to  be  drawn  between  these  two  t)^es  from  a  pathological  standpoint, 
they  differ  merely  in  severity.  Both  are  the  result  of  infective  processes  and  it 
is  difficult  to  state  why  in  one  instance  the  mild  form  is  met  and  in  another 
the  malignant. 

.Etiology.  Simple  acute  endocarditis  is  always  a  secondary  affection, 
most  often  to  acute  articular  rheumatism;  in  many  instances,  also,  it  occurs 
with  chorea;  less  frequently  it  complicates  the  acute  infectious  diseases,  especi- 
ally scarlatina  and  pneumonia,  while  it  is  less  commonly  seen  in  tonsillitis, 
erysipelas,  smallpox,  diphtheria  and  enteric  fever;  in  measles  and  varicella 
it  is  rare.  It  is  also  met  in  chronic  nephritis  and  the  chronic  wasting  diseases 
such  as  tuberculosis,  cancerous  cachexia,  diabetes  and  gout,  and  in  addition 
it  is  often  engrafted  upon  the  sclerotic  valves  of  chronic  endocarditis,  causing 
acute  exacerbations  of  the  symptoms  of  the  latter  inflammation;  the  term 
recurrent  endocarditis  has  been  applied  to  this  form  of  the  affection. 

The  bacteriology  of  simple  acute  endocarditis  following  the  infectious 
diseases  is  identical  with  that  of  the  malignant  type  of  the  disease. 

Cultures  from  the  valves  in  acute  endocarditis  due  to  the  chronic  diseases 
are  usually  sterile.  It  is  possible  that  micro-organisms  have  been  previously 
present  but  have  disappeared  or  that  the  pathological  condition  is  the  result 
of  toxic  substances. 

Malignant  endocarditis  is  also  of  infectious  nature  and  may  occur  primarily 
in  rare  instances;  much  more  often  it  is  a  secondary  affection,  being  met  most 
frequently  in  infectious  pneumonia,  acute  articular  rheumatism,  gonorrhoeal 
infection,  peliosis  rheumatica,  puerperal  fever  and  other  forms  of  septicaemia, 
and  is  distinctly  predisposed  to  by  chronic  valvular  lesions  and  congenital 
cardiac  defects.     It  is  rare  in  chorea,  tuberculosis,  scarlatina  and  the  other 


570  ISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

acute  infectious  diseases.  The  bacteria  most  often  found  in  the  valvular 
lesions  are  the  pneumococcus,  the  gonococcus,  the  staphylococcus  and  the 
streptocoecus.  Rarely  typhoid,  tubercle  and  colon  bacilli  have  been  noted. 
Mixed  infections  may  occur. 

Pathology.  The  morbid  changes  affect  the  left  side  of  the  heart  in  the 
great  majority  of  instances.  The  mitral  valve  is  most  often  involved,  then 
the  aortic,  next  the  tricuspid  and  last  the  pulmonary  valve.  The  character- 
istic lesion  is  the  occurrence  of  warty  vegetations  upon  the  valves  and  more 
rarely  upon  the  membrane  lining  the  cardiac  cavities.  Upon  the  mitral  and 
tricuspid  valves  they  are  observed  upon  the  auricular  surfaces  near  their 
margins  and  upon  the  aortic  and  pulmonary  valves  upon  the  ventricular 
aspects.  They  are  xV  to  ^  of  an  inch  (2  to  3  mm.)  in  height,  of  irregular 
surface  and  may  be  pediculated.  At  their  inception  they  consist  of  cells 
proliferated  from  the  adventitia  and  connective  tissue  of  the  outer  layers  of 
the  endocardium.  These  cells  are  infiltrated  with  red  and  white  blood  cells 
and  fibrin  which  finally  organize  and  the  vegetation  becomes  wholly  composed 
of  connective  tissue,  bits  of  which  may  become  detached  and  carried  as 
emboli  by  the  blood  current.  Micro-organisms  are  usually  found  enmeshed 
in  the  fibrin  which  often  forms  a  film  over  the  summit  of  the  vegetation.  The 
latter  may  undergo  subsequent  contraction  and  organization  and  disappear, 
not,  however,  leaving  behind  a  normal  valve,  but  one  thickened,  sclerosed  and 
contracted,  or  the  inflammatory  process  may  continue  and  go  on  to  an  endo- 
carditis of  malignant  type. 

In  malignant  endocarditis  vegetations  are  almost  constantly  present.  These 
vary  in  size  from  that  of  a  pin-head  to  that  of  a  pea  and  frequently  undergo 
ulceration  which  may  go  on  to  the  formation  of  a  valvular  aneurysm  or  to 
perforation.  The  endocardial  lining  of  the  cardiac  chambers  also  may  be 
affected,  most  frequently  in  the  left  ventricle  at  the  upper  part  of  the  septum. 
The  vegetations  in  this  type  of  endocarditis  contain  pathogenic  bacteria  in 
greater  number  than  in  the  simple  form  and  these  are  closely  intermingled 
with  masses  of  fibrin.  The  process  when  involving  the  endocardial  lining 
may  go  on  to  perforation  of  the  heart  wall.  According  to  Osier's  statistics 
of  209  patients  the  mitral  valve  alone  is  most  often  affected,  next  the  aortic, 
next  both  the  mitral  and  aortic,  next  the  mural  endocardium,  next  the  tricuspid 
and  lastly  the  pulmonary  valve.  Extension  of  the  inflammatory  process 
may  take  place  along  the  pulmonary  artery  to  the  hilum  of  the  lung  or  to  the 
aorta  producing  multiple  aneurysmal  dilatations.  Further  than  this  the 
pathological  changes  consist  of  those  due  to  the  primary  infection,  pneu- 
monia, rheumatism,  sepsis,  etc.,  and  the  lesions  due  to  the  lodgment  of  emboli 
deposited  in  various  parts  of  the  body  by  the  blood  current.  These  result 
in  the  formation  of  metastatic  abscesses  or  red  infarctions.  Emboli  may  be 
absent  or  be  numbered  by  hundreds.     They  may  be  situated  in  the  spleen, 


ACUTE    ENDOCARDITIS.  571 

kidney,  brain,  skin  or  intestines,  and,  in  endocarditis  of  the  right  heart,  in 
the  lungs. 

Symptoms.  Those  of  acute  simple  endocarditis  are  in  no  way  typical  and 
are  frequently  overlooked,  the  first  intimation  of  cardiac  involvement  being 
the  presence  of  vegetations  as  revealed  upon  the  autopsy  table.  The  symp- 
toms of  the  primary  disease  are  present  and  in  those  affections  in  which  endo- 
carditis is  prone  to  occur,  daily  examinations  of  the  heart  should  be  made. 
When  cardiac  involvement  occurs  it  may  be  evidenced  by  an  increased  rapid- 
ity and  an  irregularity  of  heart  action,  dyspnoea,  augmented  restlessness  and 
fever.  Cardiac  pain  is  rare;  palpitation  is  frequent.  The  febrile  movement 
is  not  marked— 101°  to  102°  F.  (38.4°  to  38.9°  C). 

The  physical  signs  are  not  characteristic  but  it  is  usually  upon  these  that 
the  diagnosis  is  based.  In  the  earher  attacks  the  size  of  the  heart  is  not  in- 
creased, the  apex  impulse  being  usually  in  the  normal  site  (fifth  left  inter- 
space, 3  J  inches  from  the  mid-sternal  line),  murmurs  due  to  the  valvular  les- 
ions (see  p.  576)  may  be  present  but  do  not  in  every  instance  signify  an  in- 
volvement of  the  endocardium;  a  ventriculo-systolic  bruit  at  the  apex  often 
being  the  result  of  a  myocarditis;  basic  murmurs  of  functional  character 
should  not  be  mistaken  for  true  organic  sounds. 

An  increasing  roughness  in  the  first  sound  at  the  apex  changing  to  a  dis- 
tinct murmur  may  be  an  evidence  of  endocarditis,  and  accentuation  and 
reduplication  of  the  pulmonic  second  sound  are  not  infrequent.  Endocar- 
dial murmurs  are  often  inconstant. 

The  symptoms  of  malignant  endocarditis  are  also  indefinite  but  in  most  in- 
stances the  irregular  fever,  chills  and  sweats  of  sepsis,  cerebral  symptoms  and 
prostration  are  present.  Particularly  should  we  suspect  this  condition  when 
these  symptoms  appear  with  pneumonia,  in  the  puerperium,  etc.,  and  the 
heart  should  be  carefully  examined  for  physical  signs.  Symptoms  of  embo- 
lism throw  much  light  upon  the  diagnosis;  with  cerebral  embolism  paralyses, 
delirium  or  coma  may  be  observed;  increase  in  the  size  of  the  spleen  with 
sudden  pain  referred  to  this  organ,  pain  in  the  lumbar  region  with  bloody 
urine,  the  occurrence  of  metastatic  abscesses,  impaired  sight  from  retinal 
embolism,  are  characteristic  manifestations.  The  temperature  may  be 
remittent  or  continuous,  fever  is,  however,  a  constant  symptom;  haemorrhagic 
and  erythematous  rashes  are  not  rare.  Cardiac  symptoms  such  as  dyspncea, 
palpitation  and  oppression  are  inconstant,  but  the  pulse  and  respiration  are 
increased  in  rate.  Jaundice  may  be  present,  and  albuminuria  with  casts  is 
the  rule.    Clinically  the  affection  may  be  considered  as  occurring  in  three  types : 

a.  The  septic  or  pycemic.type  which  is  usually  associated  with  wounds, 
puerperal  or  other  sepsis,  and  gonorrhoeal  infection.  Here  the  symptoms 
are  characteristic  of  septicaemia,  and  the  chills,  sweats  and  irregular  fever  may 
wholly  mask  any  cardiac  manifestations  unless  embolism  occurs.     The  tem- 


572  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

perature  may  resemble  that  of  quotidian  or  double  tertian  malaria.  The 
leucocytes  are  increased  and  pathogenic  micro-organisms  may  be  cultivated 
from  the  blood. 

b.  The  typhoid  type  is  characterized  by  a  gradual  onset,  a  temperature 
curve  resembling  that  of  enteric  fever,  sweats,  a  rash  not  unlike  that  of  typhoid, 
prostration,  drowsiness,  tympanites  and  abdominal  tenderness,  diarrhoea, 
the  typhoid  tongue  and  often  no  cardiac  symptoms.  This  is  the  most  common 
form. 

c.  The  cerebral  type  is  evidenced  by  delirium  or  coma  and  other  symptoms 
resembling  those  of  a  basilar  or  cerebrospinal  meningitis. 

The  physical  signs  are  atypical.  Murmurs  may  or  may  not  exist  and  when 
detected  may  be  inconstant  and  difficult  to  locate  and  time  with  accuracy; 
co-existent  pericarditis  and  primary  clironic  endocarditis  may  still  further 
complicate  matters. 

The  diagnosis  is  often  difficult;  in  all  fevers  of  septic  type  daily  and  most 
careful  examination  of  the  heart  should  be  performed.  The  occiirrence  of 
embolism  renders  the  diagnosis  much  more  simple.  From  enteric  fever 
the  condition  may  be  separated  by  its  less  enlarged  and  more  tender  spleen, 
by  the  presence  of  leucocytosis  and  by  the  absence  of  the  Widal  reaction; 
the  writer  recollects  a  patient  seen  several  years  ago  who  came  to  autopsy 
with  a  diagnosis  of  enteric  fever  in  whom  typical  valvular  vegetations  were 
found  and  in  whom  the  Widal  reaction  was  negative.  It  must  not  be  forgotten 
that  infarction  may  rarely  occur  in  enteric  fever.  Malaria  may  be  excluded 
by  blood  examination.  Cultural  blood  tests  in  endocarditis  usually  reveal 
the  presence  of  pathogenic  micro-organisms. 

The  prognosis  in  simple  acute  endocarditis  is  good  as  to  recovery  but  seldom 
is  the  heart  left  undamaged;  rarely,  however,  this  may  occur.  The  fact  that 
the  murmur  has  disappeared  is  by  no  means  an  assurance  that  the  valves  are 
intact  and  it  is  not  to  be  forgotten  that  successive  attacks  are  not  infrequent. 

In  malignant  endocarditis  the  outcome  is  invariably  fatal  although  the 
course  of  the  disease  may  be  prolonged  for  months;  this  may  take  place  when 
the  infection  is  superadded  to  a  chronic  valvular  defect;  the  symptoms  are  a 
persistent  temperature  with  progressive  emaciation  and  weakness,  until  at  the 
last  embolic  manifestations  may  occur.  The  usual  instance  terminates  within 
a  month  to  two  weeks.     One  instance  fatal  in  two  days  has  been  reported. 

Treatment.  Of  acute  simple  endocarditis.  Unfortunately  we  possess  no 
therapeutic  measure  whereby  we  can  cause  a  return  of  the  diseased  valve  to 
its  normal  condition,  consequently  we  should  endeavor  to  prevent  in  so  far 
as  possible  the  occurrence  of  the  endocardial  lesion.  Rheumatism,  being  the 
most  frequent  cause,  we  should  advise  aU  individuals  of  rheumatic  tendency 
to  avoid  exposure,  to  wear  proper  clothing  and  to  maintain  as  high  a  standard 
of  bodily  nutrition  as  possible.     Rheumatism  being  present,  while  it  is  by  no 


ACUTE    ENDOCARDITIS.  573 

means  certain  that  in  the  salicylates  we  have  a  means  of  preventing  the  inci- 
dence of  endocardial  inflammation,  it  should  receive  early  and  thorough 
treatment  by  the  salicylates  and  alkalies  (see  p.  117).  Where  cardiac  involve- 
ment is  present  or  there  is  any  likelihood  that  it  will  occur,  absolute  rest  in 
bed  should  be  insisted  upon;  it  is  as  important  to  keep  an  inflamed  valve 
as  nearly  at  rest  as  possible  as  it  is  to  immobilize  an  inflamed  joint.  The 
confinement  to  bed  should  be  prolonged  for  several  months  if  necessary. 
Blisters  over  the  heart  are  of  doubtful  value  but  if  the  action  of  the  organ 
is  too  rapid  or  violent  our  best  means  of  inducing  quiet  is  by  the  application 
of  the  Leiter  coil  or  the  ice  bag,  preferably  the  former  as  it  is  more  comfort- 
ably borne  by  the  patient.  If  the  circulation  becomes  depressed  hot  com- 
presses should  be  substituted  for  the  cold.  The  drug  of  most  use  as  a  heart 
tonic  and  which  should  be  administered  as  soon  as  signs  of  weakness  are 
evident,  is  strychnine.  It  may  be  given  in  doses  of  ^\  to  -j-q  of  a  grain 
(o.ooi  to  0.003)  3  times  a  day.  Aconite  has  been  recommended  as  useful 
in  conditions  of  over-action  but  is  depressant  and  altogether  less  advantageous 
than  the  application  of  cold.  Dyspnoea  may  be  relieved  by  the  administra- 
tion of  opium  or  morphine  which  act  as  heart  tonics  in  addition.  Pain  is 
not  a  common  symptom  but  may  be  combated  if  necessary  by  these  drugs 
also,  the  coal  tar  analgesics  possessing  too  depressing  an  action.  Fever 
seldom  requires  special  treatment  but  may  be  relieved  by  cool  sponging. 
Restlessness  and  sleeplessness  may  be  controlled  by  the  bromides  or  sulphon- 
methane  (sulphonal). 

The  administration  of  the  iodides  is  advocated  in  the  hope  that  these  may 
influence  the  tendency  to  the  production  of  permanent  connective  tissue 
changes  in  the  valves  and  it  is  possible  that  they  may  prove  beneficial.  Pref- 
erably we  should  give  a  drachm  (4.0)  of  the  syrup  of  hydriodic  acid  three  times 
daily,  one-half  an  hour  before  meals  in  a  wineglass  of  water,  but  potassium 
iodide  may  also  be  employed  in  doses  of  10  grains  (0.66)  three  times  a  day.  This 
treatment  should  be  continued  for  a  long  time  if  it  is  to  accomplish  any  result. 

Throughout  the  disease  the  bowels  and  kidneys  should  be  kept  active  and 
much  benefit  will  accrue  if  the  action  of  the  liver  is  stimulated  from  time  to 
time  by  a  few  fractional  doses  of  calomel  followed  by  a  saline. 

The  diet  should  be  nourishing,  easily  digestible  and  above  all  such  as  not  to 
cause  tympanitic  distention  of  the  stomach  and  intestines  which  will  greatly 
interfere  with  the  heart's  action.  Broths,  meat  juices,  eggs,  milk  and  the 
like  may  be  allowed.  Frequent  small  meals  are  much  to  be  preferred  to  fewer 
and  larger  ones. 

The  treatment  of  malignant  endocarditis  consists  first  in  the  removal  of 
the  cause  by  surgical  means  when  this  is  apparent  and  operation  is  practicable. 
The  septic  uterus  should  be  cleaned  out,  foci  of  bone  necrosis  excised,  etc.; 
rheumatism,  if  the  causal  factor,  should  receive  proper  treatment;  metas- 


574  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

tatic  abscesses  when  they  occur  should  be  opened  and  drained  if  in  such 
location  as  to  render  this  possible.  The  general  management  of  this  type  of 
acute  endocarditis  is  in  other  respects  similar  to  that  of  the  simple  form;  anti- 
streptococcus  serum  should  be  administered,  for,  while  the  results  up  to  this 
time  obtained  by  the  employment  of  this  agent  have  not  been  markedly 
encouraging,  in  some  few  instances  benefit  has  been  conferred,  and  at  any 
rate  no  harm  can  be  done.  The  ordinary  daily  dose  is  about  5  drachms  (20.0) 
given  hypodermatically.  When  the  infection  is  the  result  of  the  presence  of 
pneumococci,  gonococci  or  any  pathogenic  bacteria  save  those  of  suppuration, 
it  is  not  to  be  expected  that  this  treatment  will  do  good. 

Beer  yeast  has  accomplished  encouraging  results  in  septic  infections  of 
various  types  and  its  use  has  been  suggested  in  septic  endocarditis..  It  may 
be  given  by  mouth,  rectum  or  under  the  skin.  The  antiseptic  action  of  the 
colloidal  silver  salts  should  benefit  the  septic  condition  obtaining  in  this  affec- 
tion, consequently  we  may  employ  generous  inunctions  of  Crede's  ointment. 

CHRONIC  ENDOCARDITIS. 

Synonym.     Chronic  Valvular  Disease  of  the  Heart. 

Definition.  A  permanent  sclerotic  change  in  the  cardiac  valves  character- 
ized by  thickening,  shrinkage,  adhesions  and  calcification  of  the  flaps  and 
their  chordae  tendineaj  and  resulting  in  obstruction  or  insufficiency  of  the  cardiac 
orifices. 

Etiology.  Chronic  endocarditis  is  rarely  a  primary  affection;  in  most 
instances  the  condition  is  secondary  to  acute  endocarditis  of  rheumatic  or 
other  origin.  Other  causes  are  chronic  alcoholism,  gout,  syphilis,  plumbism, 
prolonged  muscular  over-exertion  and  rheumatism  and  other  acute  infections. 
The  sclerotic  change  which  occurs  in  all  connective  tissue  structures  as  a 
result  of  senility  renders  old  age  a  predisposing  factor.  Men  are  more  prone 
to  the  disease  than  women. 

Pathology.  The  initial  change  is  a  thickening  of  the  valve  which  begins 
at  the  edges  of  the  cusps  and  is  due  to  an  increase  in  the  normal  connective 
tissue  at  this  situation;  while  this  change  is  of  slight  degree  the  function  of 
the  valve  may  be  undisturbed  but  the  process  continues  to  advance  until  the 
entire  cusp  is  thickened  and  stiffened.  Later  the  newly  produced  tissue 
shrinks  which  causes  the  valve  flap  to  retract  and  to  become  partly  immo- 
bilized. This  shrinkage  may  involve  the  chordae  tendineae  as  well  as  the 
valve  proper  in  which  case  the  retraction  is  more  marked  and  perfect  closure  of 
the  valve  becomes  impossible.  Adhesions  between  the  cusps  now  form,  still 
further  interfering  with  their  action;  particularly  in  the  mitral  valve  is  this 
likely  to  be  a  serious  condition  since  it  may  reduce  the  mitral  opening  to  hardly 
more  than  a  slit.  Further  changes  are  the  deposition  of  lime  salts  which 
may  result  in  stiffening  of  the  valves  or  in  the  formation  of  hard  nodules  pro- 


MITRAL    INSUFFICIENCY.  575 

jecting  from  their  margins;  in  extreme  degrees  the  fibrous  ring  of  the  valve 
becomes  infiltrated  with  the  calcareous  substance  and  as  a  consequence  is 
rigid  and  almost  bony.  Fatty  degeneration  is  evidenced  by  yellow  areas 
upon  the  valvular  surfaces  or  margins.  Fibrous  changes  may  involve  the 
apices  of  the  papillary  muscles  and  there  may  be  sclerotic  patches  in  the 
endocardial  lining  of  the  walls  of  the  heart.  With  the  changes  of  chronic 
endocarditis  the  vegetations  of  an  acute  process  may  also  be  present. 

Congenital  valvular  defects  may  be  due  to  malformations  or  to  inflamma- 
tory processes  occurring  in  the  foetus.  Such  lesions  most  frequently  affect 
the  right  side  of  the  heart;  rarely  ♦hey  may  be  observed  in  the  left  side. 

The  different  valves  are  afTected  in  the  following  order  of  frequency:  (i) 
The  mitral;  (2)  the  aortic;  (3)  the  tricuspid;  (4)  the  pulmonic.  Lesions  of 
more  than  one  valve  often  co-exist. 

Mitral  Insufficiency. 

This  is  the  most  common  valvular  lesion.  The  incompetent  valve  allows 
the  blood  to  regurgitate  from  the  left  ventricle  into  the  left  auricle  during  the 
heart's  systole;  the  endeavor  of  the  auricle  to  prevent  this  back  flow  results  in 
hypertrophy,  and  ultimately  in  dilatation  and  the  backward  rush  of  blood 
to  the  lungs  results  in  congestion  of  these  organs.  Further  changes  now 
take  place  in  the  right  side  of  the  heart,  hypertrophy  of  the  right  ventricle  is 
induced  by  its  effort  to  overcome  the  pulmonary  congestion;  this  it  is  able 
to  do  for  a  time  and  during  this  period  the  right  ventricle  is  able  to  pump 
an  excessive  quantity  of  blood  through  the  lungs  to  the  left  ventricle  and 
compensation  is  furthered  by  a  hypertrophy  of  the  walls  of  this  structure  which 
now  ensues.  At  length,  however,  the  strain  becomes  too  great  for  the  right 
ventricle,  it  dilates,  producing  a  relative  insufficiency  of  the  tricuspid  valve, 
regurgitation  into  the  right  auricle  follows  with  further  backing  up  of  the 
blood  current  into  the  great  veins  of  the  neck  and  finally  a  general  systemic 
venous  congestion  takes  place. 

By  the  term  "relative  insufficiency"  employed  above  is  meant  a  condition 
of  valvular  incompetency,  due  to  no  pathological  lesion  of  the  valve,  but 
occurring  as  the  result  of  the  dilatation  of  a  heart  cavity  and  consequently 
of  its  orifices  which  the  normal-sized  valves  become  of  insufficient  size  to 
close.  This  form  of  leakage  is  observed  most  often  in  the  auriculo-ventric- 
ular  valves  and  may  not  be  detected  during  life  since  physical  signs  may  be 
wholly  absent. 

.Etiology.  Mitral  insufficiency  is  the  result  of  changes  in  the  cusps  of  the 
valve,  whereby  they  are  retracted  and  shrunken,  with  associated  sclerosis 
of  the  chordae  tendineae  or  of  dilatation  of  the  ventricular  wall  in  which  latter 
case  the  insufficiency  is  of  the  relative  type.  The  initial  cause  of  the  valvular 
incompetency  is  an  acute  or  chronic  endocarditis. 


576 


DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 


Symptoms.  While  compensation  is  sufficient  to  overcome  the  effects 
of  the  regurgitation  of  blood  through  the  leaking  valve  these  are  often  wholly 
absent,  unless  there  is  a  sudden  rupture  of  a  cusp  due  to  ulceration.  While 
compensation  is  still  good  the  patient  may  complain  of  slight  palpitation 
and  dyspnoea  on  exertion  and  facial  congestion  and  clubbing  of  the  fingers 
may  be  present.  The  initial  symptoms  of  failing  compensation  are  increas- 
ing dyspnoea  and  accompanying  palpitation  with  irregularity.  Symptoms 
due  to  the  congestion  are  now  present;  these  are  cough  with  mucoid  and  per- 
haps bloody  sputum;  attacks  of  bronchitis  are  frequent,  to  which  the  pulmon- 
ary engorgement  predisposes.  Congestion  of  the  alimentary  tract  results  in 
digestive  disorders  with  nausea  and  perhaps  vomiting,  congestion  of  the 
liver  causes  enlargement  and  sometimes  jaundice,  tenderness,  pulsation,  and 
secondary  increase  in  the  size  of  the  spleen;  to  congestion  of  the  kidneys  is 
due  albuminuria,  with  hyaline  casts  and  in  some  instances  red  blood  cells;  the 
urine  is  usually  diminished  in  quantity.  CEdema,  usually  first  involving  the  feet 
and  ankles,  now  appears  and  spreads  to  the  subcutaneous  tissue  of  other  parts 
of  the  body  and  into  the  serous  cavities,  especially  the  peritonaeum  and  pleura. 

Physical  Signs.  Inspection  reveals  an  apex  impulse  displaced  downward 
and  to  the  left,  it  is  usually  more  forcible  than  under  normal  conditions  and 
if  dilatation  is  in  excess  of  hypertrophy  it  is  diffuse  and  undulatory.  In 
emaciated  and  young  subjects  the  precordium  may  bulge  and  an  impulse  due 
to  the  systole  of  the  right  ventricle  may  be  visible  below  the  ribs  in  the  left 
parasternal  line;  pulsation  in  the  veins  of  the  neck  may  be  present. 

Palpation  confirms  the  signs  disclosed  by  inspection;  the  apical  impulse 
is  increased  in  force;  a  ventriculo-systolic  thrill  may  be  detected  at  the  apex 
in  very  rare  instances. 

Percussion  reveals  an  area  of  cardiac  dulness  increased  to  the  left,  and 
when  the  right  ventricle  is  enlarged,  beyond  the  right  border  of  the  sternum. 

Auscultation.  The  characteristic  murmur  of  mitral  insufficiency  is  a 
ventriculo-systolic  murmur,  soft  and  blowing,  and  heard  with  greatest  intensity 
at  the  apex;  it  is  transmitted  toward  the  axilla  and  often  is  audible  in  this 


TIME. 

PLACE. 

LESION. 

Auricular  systole 

At  apex 

At  xiphoid  cartilage 

Mitral  obstruction 
Tricuspid  obstruction 

Ventricular  systole 

At  apex 

At  xiphoid  cartilage 
At  2d  right  cartilage  (aortic  area) 
At  2d  left  interspace  (pulmonic 
area) 

Mitral  insufficiency 
Tricuspid  insufficiency 
Aortic  obstruction 

Pulmonic  obstruction 

Ventricular  diastole 

At  aortic  area 
At  pulmonic  area 

Aortic  insufficiency 
Pulmonic  insufficiency 

Table  of  heart  murmurs   giving  the  time  at  which  the  murmur  occurs,  the  place  at 
which  it  is  heard  with  maximum  intensity  and  the  lesion  causing  the  murmur. 


MITRAL    OBSTRUCTION.  577 

situation  and  posteriorly  at  the  level  of  the  apex  and  between  the  scapula 
and  the  vertebral  column;  when  very  loud  it  may  be  heard  over  the  entire 
chest;  it  may  wholly  or  partly  obliterate  the  first  sound  at  the  apex.  If  com- 
pensation has  failed  and  dilatation  has  taken  place  the  murmur  may  disap- 
pear and  be  replaced  by  atypical  valvular  sounds.  It  may  not  be  present  in 
all  instances  of  mitral  insufiiciency  but  it  may  be  rendered  audible,  in  many 
instances  where  it  is  apparently  absent,  by  muscular  exertion.  A  ventriculo- 
systolic  thrill  is  very  rare. 

An  important  sign  is  an  accentuation  of  the  pulmonic  second  sound  heard 
in  the  second  left  space  close  to  the  sternum;  this  is  due  to  the  increased  ten- 
sion in  the  pulmonary  artery.  If  there  is  marked  left  ventricular  hypertrophy 
the  aortic  second  sound  will  also  be  increased  in  intensity. 

The  pulse  is  practically  normal  in  the  stage  of  full  compensation;  upon 
the  onset  of  failure  of  compensation  it  becomes  irregular  in  force  and  fre- 
quency; the  irregularity  may  continue  after  the  re-establishment  of  com- 
pensation. 

The  diagnosis.  A  ventriculo-systolic  murmur,  loudest  at  the  apex,  and 
transmitted  into  the  axilla,  accompanied  by  other  signs  of  cardiac  dilata- 
tion and  hypertrophy  and  an  accentuated  pulmonic  second  sound,  is  charac- 
teristic of  mitral  insufficiency;  unfortunately  there  are  murmurs  similar  in 
character  and  transmisson  which  are  of  doubtful  origin  but  are  certainly 
not  the  result  of  valvular  defect;  these  may  be  functional  or  are  caused  by 
some  little  understood  ventricular  condition.  They  are  not  associated  with 
dilatation  or  hypertrophy  or  an  increased  pulmonic  second  sound.  The  ven- 
triculo-systolic murmur  of  aortic  obstruction  may  be  loudest  at  the  apex  but 
is  not  transmitted  to  the  left  nor  accompanied  by  an  accentuated  pulmonic 
second  sound.  The  ventriculo-systolic  murmur  of  tricuspid  insufficiency  is 
heard  with  greatest  intensity  at  the  xiphoid  cartilage.  An  associated  rumbl- 
ing auriculo-systolic  murmur  of  mitral  obstruction  is  more  likely  to  be  pres- 
ent in  true  than  in  relative  insufficiency. 

Mitral  Obstruction. 

Obstruction  of  the  mitral  orifice  is  in  almost  if  not  quite  all  instances  accom- 
panied by  mitral  insufiiciency.  Obstruction  to  the  free  passage  of  blood 
through  the  valve  is  the  result  of  thickening  and  shrinkage  of  the  mitral  ring, 
of  the  cusps  and  of  their  chordae  tendinea?.  The  blood  prevented  from 
freely  passing  into  the  left  ventricle  distends  the  left  auricle,  which  becomes 
hypertrophied,  and  is  backed  into  the  pulmonary  circulation,  the  right  ven- 
tricle and  finally  the  general  venous  circulation.  Hypertrophy  of  the  left  ven- 
tricle is  conspicuously  absent.  Compensation  may  prevent  the  appearance 
of  symptoms  for  a  long  period  of  time  but  untimately  relative  tricuspid  insuffi- 

37 


57°  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

ciency  and  systemic  congestion  occur.  In  the  milder  degrees  of  mitral  obstruc- 
tion the  orifice  may  allow  the  passage  of  a  finger  while  in  the  more  extreme 
instances  it  may  be  almost  wholly  obliterated  or  reduced  to  a  mere  slit — the 
button-hole  stenosis  of  Corrigan.  In  the  slightest  grades  of  obstruction  where 
the  edges  of  the  tiaps  are  adherent  to  one  another  the  orifice  is  funnel-shaped. 
The  chords  tendinea?  may  be  so  shrunken  that  the  papillary  muscles  seem 
to  be  inserted  directly  into  the  flaps.  The  heart  is  seldom  more  than  slightly 
enlarged,  the  increase  in  size  aft'ecting  chiefly  the  left  auricle  and  right  ventricle. 

.Etiology.  Mitral  obstruction  is  more  commonly  seen  in  young  persons, 
especially  females.  The  condition  may  rarely  be  congenital  but  is  usually 
the  result  of  an  acute  or  chronic  endocarditis.  Certain  apparently  idio- 
pathic instances  may  be  the  result  of  whooping  cough  or  of  some  other  acute 
infectious  disease. 

Symptoms.  While  compensation  is  present  these  are  absent;  after  it  has 
failed  they  are  practically  identical  with  those  of  mitral  insufiiciency. 

Physical  Signs.  The  lesion  may  exist  for  a  long  time  without  physical 
signs,  the  typical  murmur  of  this  condition  being  a  notoriously  inconstant  one. 
Upon  inspection  the  apex  impulse,  left  ventricular  hypertrophy  being  absent, 
is  seldom  found  displaced.  If  hypertrophy  of  the  right  ventricle  is  present 
the  apex  beat  may  be  slightly  to  the  left  of  and  below  its  normal  position  and 
pulsation  may  be  noticed  just  below  the  ensiform  cartilage.  The  hypertro- 
phied  left  auricle  may  produce  an  impulse,  auriculo-systolic  in  time,  in  the 
second  left  interspace  close  to  the  sternum.  After  the  failure  of  compen- 
sation a  jugular  pulsation  may  be  visible  due  to  a  relative  tricuspid  insuffi- 
ciency, and  with  this,  hepatic  pulsation  may  be  observed.  Bulging  of  the 
lower  part  of  the  sternum  and  of  the  fifth  and  sixth  left  costal  cartilages,  due  to 
enlargement  of  the  right  ventricle,  may  occur  in  poorly  nourished  children. 

Palpation  reveals  the  absence  of  increased  force  in  the  apex  impulse,  and 
if  compensation  is  disturbed,  this  may  be  weaker  than  normal,  a  palpable 
impulse  may  be  present  just  below  the  ensiform  cartilage  and  to  its  left  as  a 
result  of  right  ventricular  hypertrophy.  A  very  typical  sign  is  a  distinct 
auriculo-systolic  thrill  which  is  often  to  be  felt  at  the  apex  or  just  to  the  inside 
of  this  point.  It  is  localized,  rough  in  quality  and  often  stops,  with  a  sudden 
shock,  with  the  occurrence  of  the  apical  impulse.  This  thrill  is  not  constant 
but  is  pathognomonic  of  mitral  obstruction. 

Percussion  shows  an  enlargement  of  the  area  of  cardiac  dulness  toward 
the  right  due  to  increase  in  the  size  of  the  right  ventricle  and  to  the  left  as  a 
result  of  the  hypertrophy  of  the  left  auricle.  The  cardiac  enlargement 
is  seldom  very  marked. 

Auscultation.  The  characteristic  murmur  of  simple  mitral  obstruction  (see 
p.  576)  is  an  auriculo-systolic  murmur,  usually  rather  sharply  localized  at 
the  cardiac  apex  and  slightly  to  its  inner  side;  rarely  it  may  be  transmitted 


AORTIC    INSUFFICIENCY.  579 

upward  or  heard  posteriorly.  In  quality  it  is  rumbling,  rough,  or  purring, 
and  its  loudness  increases  until  it  terminates  suddenly  with  the  apical  first 
sound;  it  is  synchronous  with  the  thrill  spoken  of  above.  The  pulmonic  second 
sound  is  accentuated  as  a  result  of  the  hypertrophy  of  the  right  ventricle;  no 
left  ventricular  hypertrophy  being  present,  the  aortic  second  sound  is  not  inten- 
sified but  there  may  be  duplication  of  the  second  sound  at  the  base  due  to  asyn- 
chronous closing  of  the  pulmonic  and  aortic  valves. 

The  pulse  in  extreme  mitral  obstruction  is  characteristically  small;  in  the 
slighter  grades  of  the  lesion  it  may  be  unchanged.  With  the  onset  of  failing 
compensation  the  apical  murmur  and  thrill  may  disappear,  but  the  forcible 
first  sound  may  persist.  The  heart  action  becomes  irregular  and  the  gallop 
rhythm  may  occur;  there  may  be  more  apex  beats  than  palpable  radial  pulsa- 
tions, the  so-called  piilsits  bigeminus,  here  the  sphygmographic  tracing  may 
show  a  small  ascent  between  two  higher  ones. 

The  diagnosis  of  uncomplicated  mitral  obstruction,  with  the  character- 
istic auriculo-systolic  thrill  and  rumbling  murmur  which  stops  abruptly 
with  the  impact  of  the  apex  against  the  chest  wall,  and  with  an  accen- 
tuated pulmonic  second  sound  and  a  small  pulse,  is  not  difficult.  A  tricuspid 
stenosis,  which  is  a  very  rare  and  usually  congenital  lesion,  may  be  evidenced 
by  a  harsh  murmur  beginning  at  the  aortic  closure  and  covering  the  ventric- 
ular diastole  and  auricular  systole,  but  it  is  heard  over  the  xiphoid  cartilage, 
not  over  the  apex.  A  murmur  taking  place  during  ventricular  diastole  and 
auricular  systole,  heard  over  the  apex  and  at  the  second  right  space,  the  first 
half  of  which  is  harsh,  the  second  half  soft,  is  due  to  mitral  obstruc- 
tion associated  with  aortic  insufficiency.  The  so-called  Flint  murmur,  which 
is  rough  in  quality,  auriculo-systolic  in  time  and  is  heard  over  the  apex,  is  due 
to  aortic  insufficiency  and  is  accompanied  by  the  water-hammer  pulse  and 
hypertrophy  of  the  left  ventricle  and  is  not  associated  with  the  sharp,  forcible 
apical  impact.  This  last  is  also  absent  in  the  rumbling  sound  sometimes 
heard  in  adherent  pericardium.  The  fact  that  the  pressure  of  the  hyper- 
trophied  left  auricle  may  cause  pressure  paralysis  of  the  left  recurrent 
laryngeal  nerve  should  not  be  forgotten  in  connection  with  the  diagnosis  of 
aortic  aneurysm.  With  the  murmur  of  mitral  obstruction  the  soft  ventriculo- 
systolic  murmur  of  mitral  insuflaciency  is  frequently  present. 

In  obstruction  of  the  fnitral  valves  there  are  likely  to  be  recurrent  attacks 
of  valvulitis  during  which  emboli  may  be  dislodged  and  cause  various  cerebral 
disturbances. 

Aortic  Insufficiency. . 

This  lesion  may  be  the  result  of  an  enlargement  of  the  aortic  orifice  which 
the  valve  flaps  cannot  close  or  of  changes  in  the  cusps  themselves;  it  is  the 
most  grave  and  most  resistant  to  treatment  of  the  valvular  defects.     Its 


580  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

immediate  result  is  a  backward  flow  of  blood  into  the  left  ventricle  during  its 
diastole;  this  causes  the  ventricle  to  dilate  and  later  to  hypertrophy  in  order 
to  restore  the  balance  disturbed  by  the  leakage.  The  over-developed  ven- 
tricle forces  the  blood  into  the  aorta  with  such  vigor  that  it  is  fully  distended 
but  it  is  rapidly  emptied  by  the  back  flow  of  blood  through  the  incompetent 
aortic  valve  and  the  onward  flow  into  the  arterial  circulation.  This  results 
in  the  characteristic  pulse  of  this  lesion,  a  pulse  of  quick  and  extreme  rise 
and  sudden  fall.  The  left  ventricular  hypertrophy  is  often  accompanied  by 
enlargement  of  the  left  auricle  and  right  ventricle.  Dilatation  and  hyper- 
trophy are  seen  in  this  lesion  in  their  most  extreme  type  and  the  heart  of 
aortic  insufficiency  on  account  of  its  great  size  has  been  termed  the  cor  hoviniim. 
I:  often  weighs  as  much  as  35  ounces  (1050.0)  and  has  been  known  to  reach 
50  ounces  (1500.0).  The  cavities  of  the  organ  are  enlarged  and  there  may  be 
co-existent  coronary  arteriosclerosis  with  consequent  fibrous  myocarditis. 
During  life  there  may  be  signs  of  an  aortic  arch  dilated  as  a  result  of  the  con- 
tinued high  pressiure  exerted  by  the  blood  current,  but  the  vessel  may  be 
found  of  normal  size  after  death.  As  a  result  of  the  ventricular  enlargement 
relative  mitral  insufficiency  occurs  and  ultimately  the  compensation  estab- 
lished by  the  hypertrophy  of  the  right  ventricle  fails,  relative  tricuspid  insuffi- 
ciency takes  place  and  general  venous  congestion  with  its  concurrent  symp- 
toms supervenes. 

.Etiology.  Aortic  insufficiency  occurs  as  a  result  of  congenital  defects, 
particularly  union  of  two  of  the  cusps;  of  acute  or  chronic  endocarditis;  and  of 
sclerosis  of  the  valve  which  is  predisposed  to  by  prolonged  excessive  muscular 
exertion,  the  abuse  of  alcohol,  and  syphilis;  dilatation  of  the  ascending  aorta 
or  aneurysm  causes  an  enlargement  of  the  valvular  ring  which  results  in  rela- 
tive insufficiency. 

Symptoms.  During  the  stage  of  compensation  there  may  be  no  manifes- 
tations which  give  rise  to  suspicion  that  any  cardiac  affection  is  present. 
Disturbance  of  compensation  is  evidenced  by  headache,  vertigo  and  a  sensa- 
tion of  faintness,  especially  marked  if  the  patient  rises  suddenly,  and  even 
before  the  failure  of  compensation,  pain  may  be  a  distressing  symptom;  this 
may  be  dull,  aching  and  referred  to  the  precordium  or  it  may  be  sharp,  radiat- 
ing up  toward  the  neck  or  down  the  arms,  more  particularly  the  left.  Attacks 
of  angina  pectoris  may  occur.  Dyspnoea  with  palpitation,  at  first  only  upon 
exertion  but  later  appearing  spontaneously,  especially  at  night  and  rendering 
it  necessary  for  the  patient  to  sleep  with  his  head  elevated,  is  common. 
OEdema  is  frequent  but  cyanosis  is  rarely  seen.  Pulmonary  congestion  causes 
cough,  attacks  of  oedema  and  perhaps  hemoptysis.  The  patient  may  com- 
plain of  a  distressing  throbbing  in  the  head,  unpleasant  dreams  and  troubled 
sleep;  marked  cerebral  symptoms  such  as  hallucinations  and  delirium  with 
suicidal  tendencies   may   be   observed.     Embolism   is  not   uncommon   and 


AORTIC    INSUFFICIENCY.  581 

sudden  death  is  more  likely  to  take  place  in  this  than  in  any  other  valvular 
lesion;  usually  it  occurs  during  an  unusual  exertion  and  is  probably  caused 
by  interference  with  the  coronary  circulation  either  as  a  result  of  embolism 
or  the  fact  that  the  valvular  incompetence  prevents  the  proper  supply  of  blood 
from  reaching  the  heart  muscle.  An  acute  ulcerative  valvulitis  may  be 
engrafted  upon  an  insufficient  aortic  valve.  Anaemia  is  frequently  observed 
in  patients  suffering  from  this  lesion. 

Physical  Signs.  Inspection  may  reveal,  especially  in  young  and  ema- 
ciated individuals,  a  bulging  precordium.  The  apex  impulse  is  displaced 
downward  and  to  the  left  even  as  far  as  the  seventh  space  and  the  anterior  axillary 
line;  if  compensation  is  disturbed  the  apex  beat  is  diffuse  and  heaving.  The 
nails  may  blanch  with  the  diastole  (Quincke's  sign).  Palpation  cor^irms 
these  signs  and  rarely  may  detect  a  ventriculo-diastolic  thrill  at  the  base  or 
in  the  epi-sternal  notch.  There  may  be  a  ventriculo-systolic  depression  of 
the  intercostal  spaces  near  the  sternum  due  to  atmospheric  pressure. 

Percussion  shows  a  heart  of  greater  size  than  is  found  in  any  other  valvular 
defect.  The  cardiac  dulness  is  increased  downward  and  to  the  left  as  a  result 
of  the  left  ventricular  hypertrophy  and,  in  extreme  instances,  enlargement  exists 
upward  and  to  the  left  as  well,  in  which  case  it  is  due  to  upward  enlargement 
of  the  left  ventricle  and  increase  in  the  size  of  the  left  auricle. 

Auscultation  detects  the  characteristic  murmur  of  the  lesion,  ventriculo- 
diastolic  in  time,  and  of  greatest  intensity  over  the  second  right  space  close 
to  the  sternum  or  at  this  level  over  the  mid-sternum.  It  is  also  in  frequent 
instances  loudly  audible  along  the  left  border  of  the  sternum  even  as  low  as 
the  ensiform  cartilage.  It  is  transmitted  over  a  wider  area  than  any.  of  the 
other  cardiac  murmurs,  being  usually  conducted  down  the  sternum  or  even 
as  far  toward  the  left  as  the  axilla.  It  is  not  carried  with  any  great  degree 
of  distinctness  upward  in  the  direction  of  the  cervical  vessels.  In  quality  it 
is  loud,  prolonged  and  blowing  and  while  not  harsh,  possesses  more  of  this 
element  than  does  the  murmur  of  aortic  obstruction.  The  so-called  "Flint 
murmur"  (see  p.  579)  may  be  co-existent. 

Upon  placing  the  stethoscope  over  the  carotid  arteries  the  second  arterial 
sound  is  less  distinct  than  under  ordinary  conditions  and  may  be  absent,  and 
the  murmur  caused  by  the  leakage  of  the  blood  through  the  incompetent 
aortic  valve  may  be  audible;  a  short  rough  murmur  ventriculo-diastolic 
in  time  may  be  heard  as  well.  Ventriculo-diastolic  and  ventriculo-systolic 
murmurs  may  also  be  heard  over  the  large  peripheral  arteries,  especially  the 
femoral  and  popliteal. 

The  pulse  of  aortic  insufficiency  is  characteristic;  its  rise  is  quick  and  to  an 
unusual  height  and  it  falls  even  more  abruptly,  as  the  blood  flows  back  through 
the  imperfectly  closed  valve  from  the  aorta  into  the  left  ventricle:  Its  force 
is   good  and  its  rhythm  regular  except  in  disordered  compensation.     This 


582  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

pulse  is  known  as  the  "Corrigan,"  "water-hammer"  or  "shot"  pulse  and 
may  be  often  detected  by  the  eye  above  the  bend  of  the  elbow  when  the  patient's 
hand  is  elevated.  The  throbbing  of  the  carotid  arteries  is  often  visible  and 
the  impulse  of  the  abdominal  aorta  may  cause  an  epigastric  pulsation.  Retinal 
pulsation  may  be  detected  by  means  of  the  ophthalmoscope  and  a  capillary 
pulse  may  be  observed  under  the  finger  nails  and  by  drawing  a  line  across 
the  forehead  or  cheek  upon  either  side  of  which  the  skin  flushes  and  pales 
with  cardiac  systole  and  diastole. 

Patients  with  uncomplicated  aortic  insufficiency  may  maintain  good  compen- 
sation for  long  periods  and  even  perform  moderately  hard  labor,  but  when 
there  are  associated  valvular  lesions,  arterial  or  myocardial  disease,  disturbance 
of  compensation  soon  occurs. 

Aortic  Obstruction. 

True  and  uncomplicated  stenosis  of  the  aortic  valve  is  one  of  the  rarest 
of  valvular  defects  but  roughening  of  the  segments,  with  or  without  obstruction 
to  the  flow  of  the  blood  current,  is  less  infrequent.  With  mere  roughening 
of  the  aortic  lining  beyond  the  valve  there  is  commonly  a  murmur  present 
which  differs  only  slightly  if  at  all  from  that  of  true  aortic  stenosis.  In  pure 
stenosis  of  moderate  degree  the  valve  cusps  are  adherent  and  so  stiffened  that 
during  the  systole  of  the  ventricle  they  do  not  fall  back  against  the  wall  of  the 
aorta  but  obstruct  the  emerging  blood  current  to  a  greater  or  less  extent;  in 
advanced  grades  of  the  lesion  the  segments  are  thickened  and  hardened  and 
may  be  converted  into  calcareous  masses.  The  obstruction  prevents  the  flow 
of  blood  into  the  aorta  and  in  consequence  left  ventricular  hypertrophy  ensues 
which  compensates  for  the  stoppage.  Until  compensation  becomes  disturbed 
the  rest  of  the  heart  remains  in  its  normal  condition  but  when  failure  takes 
place,  dilatation  ensues  with  consequent  pulmonary  congestion  and  hyper- 
trophy of  the  right  heart. 

A  relative  aortic  obstruction  may  result,  when  the  valves  remain  normal 
but  there  is  dilatation  of  the  first  part  of  the  aorta. 

.Etiology.  Aortic  obstruction  is  most  frequently  met  in  patients  of  advanced 
years  and  is  usually  associated  with  calcareous  degeneration  of  the  arteries. 

Symptoms.  While  compensation  persists  the  symptoms  are  insignificant 
but  there  may  be  vertigo  and  syncopal  attacks  due  to  insufficient  cerebral 
and  cardiac  blood  supply.  Pain  and  symptoms  of  angina  may  be  induced 
by  exertion  but  are  less  common  than  in  aortic  insufficiency.  Failure  of 
compensation  is  followed  by  the  usual  symptoms  of  venous  congestion,  dysp- 
noea, cough,  palpitation  and  oedema. 

Physical  Signs.  Inspection  reveals  an  apex  beat  displaced  to  the  left, 
the  degree  of  the  displacement  depending  upon  the  amount  of  ventricular 


TRICUSPID    INSUFFICIENCY.  583 

hypertrophy;  the  apical  impulse  may  be  of  good  force  if  compensation  is 
present;  when  the  latter  is  disturbed  and  even  before  this  event,  it  may  be 
weak  and  indistinct. 

Palpation  confirms  the  signs  detected  by  inspection;  a  thrill  may  be  present 
at  the  base  and  apex,  rarely  at  the  apex  only,  and  in  certain  instances  of  extreme 
hypertrophy  there  may  be  a  prominence  of  the  precordium.  Permission 
shows  an  increase  of  precordial  dulness,  especially  downward  and  to  the  left. 

Upon  auscultation  a  ventriculo-systolic  murmur  is  detected,  loudest  over  the 
second  right  interspace  close  to  the  sternum  and  sometimes  accompanied  by  a 
thrill.  The  bridt  is  harsh  when  there  is  roughening  of  the  aortic  lining; 
after  disturbance  of  compensation  it  may  become  soft  and  more  musical. 
The  murmur  is  transmitted  upward  along  the  course  of  the  blood  current 
and  may  be  audible  in  the  popliteal  and  dorsal  arteries  of  the  feet.  There 
may  be  a  co-existent  ventriculo-diastolic  murmur  due  to  associated  aortic 
insufficiency;  the  double  murmur  of  these  lesions  when  occurring  together 
may  be  mistaken  for  the  bruit  of  aortic  aneurysm  (see  p.  614). 

The  pulse  is  usually  smaD,  its  upward  stroke  is  tardy,  and  its  rate  may  be 
slow  but  is  more  often  frequent;  it  is  regular  while  compensation  persists. 

The  diagnosis  of  aortic  obstruction  is  often  difficult  on  account  of  the 
great  similarity  between  its  murmur  and  that  of  simple  aortic  roughening; 
with  the  latter  condition  the  pulse  is  less  small  and  no  thrill  is  present.  Func- 
tional murmurs  which  are  so  often  heard  at  the  base  are  more  common  in 
young  persons,  are  associated  with  anaemia,  are  not  accompanied  by  a  thrill 
nor  by  any  cardiac  hypertrophy  and  are  frequently  intermittent. 

Tricuspid  Insufficiency. 

Primary  insufficiency  of  the  tricuspid  valve  is  very  rare  but  may  occur 
as  a  congenital  defect;  in  certain  instances  it  is  observed  as  a  result  of  acute 
or  chronic  endocarditis;  secondarily  the  lesion  takes  place  as  a  result  of  valvu- 
lar affections  in  the  left  heart  and  is  of  the  relative  type.  It  is  also  met  as  a 
complication  of  conditions  which  cause  pulmonary  congestion,  such  as  chronic 
bronchitis,  pulmonary  emphysema  and  fibroid  phthisis. 

Symptoms.  These  have  been  discussed  at  length  in  the  section  devoted 
to  mitral  insufficiency  and  are  those  of  obstruction  to  the  pulmonary  circula- 
tion with  congestion  of  the  stomach,  kidneys  and  liver,  with  enlargement  and 
tenderness  of  the  last  organ,  and  anasarca.  Late  manifestations  are  cyanosis, 
dyspnoea  and  pulmonary  oedema. 

Physical  Signs.  Inspection  reveals  a  diffuse  pulsation  in  the  region  of  the 
xiphoid  cartilage  and  a  pulsation  of  the  liver  and  of  the  jugular  veins.  The 
latter  is  ventriculo-systolic  in  time  and  more  forcible  in  the  vessel  of  the  right 
side.     Upon  coughing  the  vein  may  form  a  tumor-like  protrusion;  in  some 


584  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

subjects  the  pulsation  may  be  observed  in  the  subclavian,  axillary  and  even 
in  the  cutaneous  veins  over  the  shoulder  and  breast.  The  hepatic  pulsation 
is  also  ventriculo-systolic,  the  impulse  resulting  from  the  tricuspid  incom- 
petence being  transmitted  through  the  inferior  cava  to  the  veins  of  the  liver. 

Palpation  confiims  the  signs  detected  by  inspection.  Percussion  deter- 
mines an  area  of  cardiac  dulness  enlarged  to  the  right  margin  of  the  sternum, 
the  result  of  right  ventricular  hypertrophy. 

Auscultation  reveals  a  ventriculo-systolic  murmur,  the  maximum  intensity 
of  which  is  over  the  sternum  just  above  the  ensiform  cartilage.  In  quality 
it  is  soft  and  usually  faint;  it  may  be  transmitted  to  the  right  as  far  as  the 
anterior  axillary  line.  It  is  often  quite  definitely  localized  to  the  tricuspid 
area.  The  pulmonic  second  sound  may  be  accentuated.  The  relative 
tricuspid  insufficiency  occurring  with  mitral  insufficiency  may  not  be  evidenced 
by  a  murmur;  here  the  valve  may  be  in  perfectly  normal  condition,  and  the 
incompetency  is  the  result  of  a  dilatation  of  the  valvular  ring. 

The  diagnosis  is  simple  when  pulsation  is  present  in  the  cervical  veins 
and  in  the  liver,  these  being  pathognomonic  signs.  In  many  instances  of 
relative  tricuspid  insufficiency  where  the  lesion  is  secondary  to  mitral  disorder, 
no  murmur  is  present  and  the  complicating  affection  may  remain  undiagnos- 
ticated  until  after  death.  In  the  differentiation  of  the  tricuspid  ventriculo- 
systolic  souffle  from  that  of  mitral  insufficiency  the  difference  in  location, 
quality  and  transmission  are  points  to  be  remembered. 

Tricuspid  Obstruction. 

Isolated  tricuspid  obstruction  is  a  very  rare  condition  but  as  a  secondary 
lesion  to  disease  of  the  left  heart,  especially  mitral  obstruction,  it  is  not  infre- 
quently observed;  it  also  occurs  as  a  congenital  defect  together  with  other 
valvular  affections.  It  seems  to  be  more  common  in  women  than  in  men. 
The  changes  in  the  valve  are  analogous  to  those  taking  place  as  a  result  of 
like  causes  in  other  valves  and  the  symptoms  also  resemble  those  due  to 
similar  lesions  occurring  in  other  parts  of  the  heart.  In  advanced  instances 
the  more  typical  manifestations  are  cyanosis  of  the  face  and  intense  and  per- 
sistent oedema. 

Physical  Signs.  Enlargement  of  the  right  side  of  the  heart  is  evident  upon 
percussion,  dulness  being  perceptible  as  far  as  the  right  margin  of  the  sternum. 
A  murmur  beginning  at  the  closure  of  the  aortic  valves,  covering  ventricular 
diastole  and  auricular  systole,  harsh  in  quality,  accompanied  by  a  thrill  and 
ceasing  abruptly  with  the  impact  of  the  apex  against  the  thoracic  wall,  is  an 
evidence  of  extreme  tricuspid  obstruction.  This  is  a  bruit  practically  identical 
with  that  of  mitral  obstruction,  but  the  latter  is  heard  over  the  apex.  The 
two  lesions  are  often  co-existent  and  the  signs  of  the  latter  may  so  obscure 


PULMONIC    INSUFFICIENCY.  585 

those  of  the  former  as  to  render  very  difficult  the  diagnosis  of  the  secondary- 
condition.  In  many  subjects  a  tricuspid  obstruction  may  exist  without 
giving  definite  signs. 

Pulmonic  Insufficiency. 

This  is  a  rare  condition  but  may  occur  as  a  congenital  lesion  and  it  has  been 
observed  in  malignant  endocarditis. 

The  symptoms  are  those  of  venous  congestion. 

Physical  Signs.  There  is  increase  to  the  right  in  the  area  of  cardiac  dulness 
due  to  hypertrophy  of  the  right  ventricle  and  in  the  later  stages  there  may  be 
pulsation  in  the  veins  of  the  neck.  The  characteristic  murmur  is  ventriculo- 
diastolic  in  time,  heard  with  maximum  intensity  over  the  pulmonic  area — 
the  second  left  space  close  to  the  sternum.  It  is  to  be  differentiated  from 
the  hruit  of  aortic  insufficiency  by  the  absence  of  the  characteristic  pulse  of 
this  lesion  and  the  lack  of  left  ventricular  hypertrophy.  Very  high  pressure 
in  the  pulmonary  artery  may  cause  slight  regurgitation  through  the  valve 
and  a  consequent  soft  ventriculo-diastolic  murmur. 

Pulmonic  Obstruction. 

This  is  a  very  rare  lesion;  when  it  does  occur  it  usually  exists  as  a  result 
of  congenital  cardiac  disease  and  may  be  associated  with  anomaly  of  the 
tricuspid  valve  and  of  the  inter-ventricular  septum  and  patency  of  the  ductus 
arteriosus  or  foramen  ovale.  Malignant  valvulitis  has  been  known  to  involve 
the  pulmonic  valve.  When  the  defect  is  congenital  the  insufficiency  is  due 
to  a  union  of  the  margins  of  the  cusps. 

The  chief  symptoms  of  pulmonic  obstruction  are  those  due  to  venous 
obstruction,  particularly  cyanosis  and  dyspnoea.  It  is  one  of  the  lesions  which 
may  cause  the  blueness  of  the  so-called  "blue  baby." 

Physical  Signs.  These  are  often  indefinite;  there  is  right  ventricular  hyper- 
trophy with  consequent  increase  in  the  area  of  cardiac  dulness  toward  the 
right  border  of  the  sternum.  The  tx'pical  murmur  occurs  with  ventricular 
systole  and  is  heard  loudest  over  the  second  left  space  close  to  the  sternum; 
a  thrill  may  be  present.  The  pulmonic  second  sound  may  be  faint  or  inaudible. 
At  times  the  murmur  is  heard  posteriorly  between  the  shoulders. 

The  frequency  with  which  murmvirs  are  audible  at  the  pulmonic  area  is 
remarkable  but  the  clinician  should  be  very  chary  of  attributing  these,  in  the 
majority  of  instances,  to  defects  of  the  pulmonic  valve  which  are  extremely 
rare.  Anaemic  murmurs  are  often  heard  in  this  region  as  also  are  the  func- 
tional bruits  which  occur  when  the  heart  is  beating  with  undue  force  as  during 
febrile  disease  or  after  unusual  muscular  exercise.     In  healthy  individuals  a 


586  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

murmur  may  be  heard,  particularly  if  the  thoracic  wall  is  thin,  over  the  base 
of  the  heart  and  the  cardio-respiratory  souffle  may  be  noted  in  this  vicinity. 
None  of  the  above  conditions  is  accompanied  by  other  evidences  of  cardiac 
disease  and  the  associated  murmur  should  never  be  mistaken  for  that  which 
evidences  a  defect  of  the  pulmonic  valve. 

The  murmiur  of  mitral  insufficiency  may  be  heard  as  far  up  the  left  border 
of  the  sternum  as  the  second  cartilage  but  the  differentiation  of  this  lesion 
from  those  of  the  pulmonic  valve  should  be  made  with  ease  (see  p.  577). 

Combined  Valvular  Lesions. 

It  is  not  at  all  infrequent  to  find  associated  lesions  of  two  or  more  valves; 
the  mitral  and  aortic  valves  are  very  often  jointly  affected  as  are  the  mitral 
and  tricuspid.  Aortic  defects  more  commonly  exist  independently  than 
those  of  the  mitral  valve  but  disease  of  the  aortic  valve  is  less  likely  to  be 
accompanied  by  mitral  stenosis  than  by  insufficiency.  In  children  a  frequent 
combination  is  insufficiency  of  both  the  aortic  and  the  mitral  valve.  A 
stenosis  occurring  with  an  aortic  or  mitral  insufficiency  may  be  beneficial 
in  that  it  prevents  too  free  regurgitation  of  the  blood  current. 
• 

Congenital  Cardiac  Defects. 

These  most  frequently  affect  the  right  side  of  the  heart  and  may  be  the 
result  of  inflammations  occurring  during  intra-uterine  life  or  of  anomalies 
of  development.  In  most  instances  they  are  incompatible  with  the  continu- 
ance of  life  or  if  not,  little  can  be  accomplished  by  curative  or  palliative  measures. 
Pulmonic  obstruction  is  the  most  frequent  lesion  and  other  lesions  which  may 
be  observed  are  persistence  of  the  foramen  ovale,  of  the  ductus  Botali,  a 
patulous  inter-ventricular  septum  and  a  persistent  communication  between 
the  aorta  and  the  vena  cava  or  between  the  aorta  and  the  right  auricle.  The 
exact  diagnosis  of  the  lesion  in  a  given  case  is  difficult  since  the  murmurs 
present  are  not  characteristic  but  the  symptoms  of  congenital  heart  disease 
are  typical.  The  most  salient  of  these  are  insufficient  physical  develop- 
ment, persistent  cyanosis  (the  "blue  baby"),  dyspnoea  and  clubbing  of  the 
fingers.     The  murmur  is  usually  basic. 

Various  malformations  of  the  heart  have  been  described,  such  as  entire 
absence  of  the  organ — acardia;  double  heart;  dextrocardia,  in  which  the  heart 
is  in  the  right  side  of  the  thorax  and  with  which  transposition  of  the  other 
viscera  may  or  may  not  co-exist;  and  ectopia  cordis  where  the  organ  may  be 
located  in  the  neck,  thorax  or  abdomen.  Fission  of  the  thoracic  wall  and 
of  the  abdomen  is  associated  with  the  last  named  condition.  The  semi- 
lunar valves  may  be  two  in  number  instead  of  three  owing  to  a  union  of  two 


THE    TREATMENT    OF    VALVULAR    LESIONS.  587 

of  the  cusps   (the  bicuspid   condition),   and  the   semilunar  cusps  may  be 
fenestrated. 

The  Prognosis  in  Chronic  Valvular  Lesions. 

The  outcome  of  any  instance  of  chronic  valviilar  endocarditis  is  difl&cult  of 
prophecy  since  the  factors  which  may  influence  it  are  numerous  and  uncer- 
tain. The  problem  depends  wholly  upon  how  long  compensation  can  be 
maintained.  Women  seem  to  withstand  the  effects  of  valvular  defects  better 
than  men,  possibly  because  their  habits  and  mode  of  life  are  more  quiet  and 
because  the  aortic  valve  is  less  frequently  affected.  Child-bearing  is  fre- 
quently fraught  with  no  ill-effects.  In  children  the  prognosis  is  bad,  the 
subjects  of  congenital  heart  disease  seldom  surviving  more  than  a  few  years, 
while  in  those  below  the  age  of  ten  or  twelve  valvular  lesions  are  serious  even 
though  the  coronary  circulation  and  the  myocardium  are  likely  to  be  in  good 
condition.  Much  depends  upon  the  maintenance  of  proper  nutrition  and 
the  abstinence  from  violent  exercise.  Children  affected  with  chronic  endo- 
carditis seldom  die  suddenly. 

With  regard  to  the  prognosis  of  the  lesions  of  the  different  valves  it  may  be 
said  that  mitral  defects  are,  other  things  being  equal,  less  serious  than  those 
of  the  aortic  valve,  especially  insufficiency,  in  which  sudden  death  often  takes 
place.  The  co-existence  of  a  certain  amount  of  obstruction  with  a  valvular 
insufficiency  is  conservative,  the  stenosis  preventing  the  regurgitation  in  some 
degree.  In  giving  the  prognosis  in  any  valvular  lesion  we  must  take  into 
consideration  the  condition  of  the  heart  muscle  and  of  the  arterial  system 
and  the  general  health  and  mode  of  life  of  the  patient,  as  well  as  the  amount  of 
compensation  present  and  the  predisposition  to  rheumatism. 

Intercurrent  disease  of  even  mild  type  is  a  serious  matter  to  the  patient 
whose  cardiac  valves  are  affected;  especially  is  any  pulmonary  trouble 
likely  to  result  unfavorably. 

The  Treatment  of  Valvular  Lesions. 

Prevention  consists  in  the  proper  treatment  of  all  diseases  which  are  likely 
to  be  followed  by  cardiac  defects,  especially  rheumatism  and  chorea.  All 
rheumatic  patients  should  receive  prolonged  salicylate  treatment,  for  whether 
or  not  this  class  of  drug  influences  the  incidence  of  heart  lesions,  it  certainly 
shortens  the  attack  of  rheumatism  and  in  connection  with  prolonged  rest 
renders  relapse  more  unlikely.  Subjects  predisposed  to  rheumatism  should  be 
advised  to  avoid  aU  exposure  and  every  influence  which  may  induce  an  attack. 

I.  Treatment  during  the  stage  0}  compensation.  At  this  time  the  object 
should  be  to  maintain  the  strength  of  the  heart  and  to  preserve  the  compen- 


588  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

satory  condition  as  long  as  possible.  This  is  to  be  accomplished  by  properly 
managing  the  patient's  mode  of  life.  Cardiac  tonics  are  not  indicated  and 
are  harmful.  Fortunately  we  are  getting  beyond  the  time  when  the  detection 
of  a  cardiac  murmur  was  a  signal  for  a  prescription  containing  digitalis. 
At  present  when  the  physician  elicits  the  physical  signs  which  lead  him  to 
make  the  -diagnosis  of  a  chronic  valvular  defect  he  must  decide  whether  or 
not  to  tell  the  patient  of  his  infirmity.  The  decision  should  be  in  the  affir- 
mative if  the  patient  is  of  calm  and  steady  mind  and  is  leading  a  life  preju- 
dicial to  the  continuance  of  the  compensated  condition  of  his  heart.  If 
the  subject  in  hand  is  hysterical  and  his  habits  are  such  as  are  not  damaging 
to  the  cardiac  condition  it  is  better  to  let  him  continue  in  a  state  of  blissful 
ignorance;  a  member  of  the  family  or  a  near  friend,  however,  should  be 
informed  that  heart  disease  is  present.  In  certain  instances,  even  in  this 
latter  type  of  patient,  when  the  habits  of  life  must  be  regulated,  it  may  become 
necessary  to  appraise  the  individual  of  his  condition  even  at  the  risk  of  render- 
ing him  hypochondriacal. 

With  regard  to  exercise  during  the  stage  of  compensation  no  fixed  rules 
can  be  laid  down  but  it  may  be  stated  in  general  that  exercise  which  is  not 
followed  by  palpitation,  dyspnoea  and  cardiac  distress  may  be  allowed,  and 
even  may  prove  beneficial.  The  more  violent  forms  of  exercise  should  be 
forbidden  in  mitral  obstruction,  but  golf,  slow  bicycle  riding,  rowing  in  moder- 
ation, bowling,  etc.,  are  allowable,  while  tennis,  boxing,  fencing,  wrestling,  run- 
ning and  the  like  should  be  tabooed.  In  young  persons  affected  with  aortic 
insufficiency,  the  more  strenuous  varieties  of  exercise  may  be  undertaken, 
but  only  when  the  heart  muscle  is  unaft'ected  and  the  arterial  system  is  in 
good  condition. 

The  occupations  suitable  for  patients  possessing  valvular  defects  are  of  nec- 
essity limited  to  those  of  sedentary  type  such  as  desk-work  of  the  various  kinds, 
tailoring,  shoe  and  harness  making  and  the  like.  Aortic  affections  when 
well  compensated  need  not  preclude  the  carpenter  and  machinist,  when 
heavy  lifting  is  avoided,  from  continuing  their  avocations  and  out-door  work  of 
light  character  may  prove  rather  beneficial  than  otherwise.  Professional  life 
such  as  that  of  the  architect,  designing  engineer,  newspaper  worker,  etc.,  may  be 
continued  but  the  public  speaking  demanded  in  certain  kinds  of  law  practice 
and  of  the  clergyman  is  likely  to  put  too  great  a  strain  upon  the  weakened 
heart,  as  is  the  general  practice  of  medicine;  an  office  or  consultation  practice, 
however,  may  be  continued  by  the  physician  who  is  unfortunate  enough  to 
possess  a  valvular  lesion.  Vocations  which  entail  severe  nervous  strain  are 
quite  as  harmful  as  those  which  tax  the  muscular  system. 

Concerning  habits  it  may  be  said  that  the  use  of  alcohol  is  in  most  instances 
harmful  but  there  are  patients  whose  custom  it  has  been  to  take  a  moderate 
amount  of  wine  or  beer  with  meals  and  in  whom  the  appetite  and  digestion 


THE    TREATMENT    OF    VALVULAR    LESIONS.  589 

suffer  if  these  are  discontinued;  to  such  we  may  allow  the  milder  alcoholic 
beverages  in  moderation,  diminishing  the  amount  as  much  as  possible.  To- 
bacco in  moderation  may  be  indulged  in  if  absolutely  necessary  to  the  patient's 
comfort,  but  it  is  better  if  he  can  be  persuaded  to  give  it  up  entirely.  Smoking 
certainly  can  produce  no  benefit  and  may  be  productive  of  harm.  With  regard 
to  the  mode  of  employment  of  the  tobacco  there  is  little  to  be  said;  it  is  the 
amount  of  the  drug  which  is  taken  which  should  be  regulated.  It  makes 
little  difference  whether  the  same  quantity  of  tobacco  is  consumed  in  the 
form  of  the  cigar,  the  cigarette  or  in  the  pipe.  Inhalation  of  the  smoke  is 
especially  harmful.  Smoking,  of  course,  should  be  forbidden  if  it  appears 
to  injure  the  patient. 

While  excessive  indulgence  in  the  sexual  act  is  distinctly  prejudicial,  married 
life  and  even  the  bearing  of  children  need  not,  in  many  instances,  be  advised 
against.  Many  women  have  passed  through  uneventful  pregnancies  and 
labors  whose  heart  valves  have  been  far  from  normal.  In  general  we  may 
state  that  while  pregnancy  is  a  grave  consideration  in  compensated  valvular 
disease  it  is  by  no  means  always  dangerous.  Labor  is,  however,  fraught  with 
peril,  particularly  when  mitral  lesions  exist,  and,  for  its  safe  consummation, 
depends  upon  the  character  of  the  compensation.  The  physician  is  justified 
in  advising  the  artificial  emptying  of  the  uterus  when  danger  of  disturbance 
of  the  compensation  is  imminent  or  this  event  has  already  taken  place. 

The  clothing  should  be  of  weight  adapted  to  the  season  of  the  year  and 
sufiiciently  warm  to  prevent  chilling  of  the  body.  Woolen  underclothing 
is  always  to  be  advised  and  particular  attention  should  be  given  to  the  extremi- 
ties which  should  never  be  allowed  to  become  cold  or  wet.  Tight  garments, 
especially  the  corset  when  laced  so  snugly  as  to  constrict  the  waist  to  the 
slightest  degree,  are  harmful,  and  women  should,  if  possible,  be  persuaded 
to  wear  their  skirts  suspended  from  the  shoulders. 

The  patient's  food  should  be  properly  cooked,  easy  of  digestion  and  of 
sufficient,  but  not  too  great  quantity.  Much  liberty  may  be  allowed  in  choos- 
ing the  dietary  but  regularity  of  meal  times  is  important.  With  regard  to 
the  different  classes  of  foods  it  may  be  said  that  patients  who  engage  in  active 
muscular  exercise  need  more  proteids  than  those  who  lead  more  sedentary 
lives  and  that  anaemic  subjects  should  be  fed  liberally  upon  those  articles 
from  which  the  organism  may  obtain  iron. 

Bathing  should  not  be  indulged  in  to  too  great  an  extent  and  should  be 
regulated  in  accordance  with  the  reaction  obtained.  Hot  tub  baths  often 
have  a  weakening  effect  and  for  them  daily  sponging  off  of  the  body,  with  a 
tepid  tub  once  or  twice  a  week,  should  be  substituted.  If  the  cool  bath  followed 
by  a  brisk  rubbing  with  a  coarse  towel  is  not  followed  by  a  healthy  glow  of 
the  skin  and  a  sensation  of  stimulation  it  should  not  be  allowed.  Sea  and 
fresh  water  bathing  influence  the  patient's  condition  both  because  of  the  shock 


590  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

caused  by  entering  the  usually  cool  water  and  through  the  exertion  necessary 
in  swimming.  These  factors  put  a  considerable  strain  on  the  heart  and  often 
one  which  the  organ  is  ill  able  to  sustain,  consequently  this  form  of  bathing 
should  hardly  be  indulged  in  by  those  with  mitral  defects  and  by  others  only 
in  the  greatest  moderation.  The  baths  provided  by  the  various  hydro- 
pathic institutions  should  be  taken  only  upon  the  advice  of  a  physician  who 
can  watch  the  effect  upon  the  patient  in  hand. 

All  intercurrent  illness  should  be  promptly  treated,  particularly  if  the  lungs 
are  involved  and  in  the  case  of  the  acute  infectious  diseases,  and  any  systemic 
disorder  such  as  anaemia,  should  be  corrected.  The  digestive  system  needs 
attention  in  many  instances  and  constipation  is  an  especially  important  con- 
sideration. 

Patients  who  are  accustomed  to  living  at  a  high  altitude  may  be  able  to  main- 
tain life  with  comfort  at  such  a  level  even  after  the  incidence  of  a  cardiac 
lesion  and  it  is  probable  that  heart  patients  can  endure  considerable  elevation 
(6,000  feet  or  perhaps  more)  if  they  remain  at  rest  when  first  coming  to  such 
an  altitude  and,  having  become  inured  to  the  change,  abstain  from  exercise; 
yet  it  is  hardly  legitimate  to  advise  the  subjects  of  valvular  defects  to  exchange 
a  low  altitude  for  a  high  one  unless  the  circumstances  render  it  necessary. 

The  precordial  distress  that  is  often  complained  of  even  while  compensa- 
tion is  good,  together  with  the  dizziness  and  palpitation  which  so  often  accom- 
pany this  symptom,  may  be  relieved  by  a  few  days  in  bed  and  the  adminis- 
tration of  small  doses  of  strychnine  or  of  10  to  20  drops  (0.66  to  1.33)  of  the 
fluidextract  of  cactus  taken  three  times  a  day.  If  there  is  tendency  to  vascular 
spasm  or  arterial  hypertension  this  may  be  combated  by  glyceryl  nitrate 
(nitroglycerin)  in  doses  of  j-^q  of  a  grain  (0.0006)  three  or  four  times  a  day. 

2.  The  treatment  of  disturbed  compensation.  The  earlier  symptoms  of 
this  stage  are  dyspnoea  upon  exertion  or  coming  on  during  the  night,  loss 
of  flesh  and  anaemia;  later  the  signs  of  cardiac  dilatation  are  noted,  the  heart's 
action  becomes  irregular,  venous  congestion  is  evident  and  oedema  may 
appear.  Upon  the  onset  of  these  symptoms  absolute  rest  in  bed  should  be 
insisted  upon  and  it  is  surprising,  in  many  instances,  to  observe  the  effects  of 
this  simple  procedure  when  instituted  in  connection  with  the  carefully  regu- 
lated diet  and  thorough  clearing  of  the  bowels.  If  the  patient  is  unable  to 
breathe  comfortably  while  in  the  recumbent  position  he  may  be  propped  up  by 
pillows  or  by  the  back  rest  which  is  in  common  use  in  hospitals. 

With  regard  to  drugs  we  have  three  factors  upon  which  to  base  our  treat- 
ment. These  are:  first  and  most  important:  The  condition  of  the  arterial 
system.  The  consideration  of  this  should  dominate  our  entire  management 
of  the  patient  and  determines  the  result  which  we  are  able  to  accomplish.  Sec- 
ond: The  condition  of  the  muscular  wall  of  the  heart.  Third  and  least  to 
be  considered:     The  valvular  lesion  itself. 


THE    TREATMENT    OF    VALVULAR    LESIONS.  59 1 

Probably  no  drug  has  enjoyed  a  greater  vogue  in  the  treatment  of  valvular 
heart  disease  than  digitalis  although  its  field  of  usefulness  is  limited.  Its 
advantages  are  that  by  slowing  the  pulse  rate  it  gives  the  heart  opportunity 
to  rest  and  improves  the  nutrition  of  the  walls  of  the  heart  by  its  stimulating 
influence  upon  the  pneumogastric  nerve,  as  well  as  by  increasing  the  blood 
supply  of  the  cardiac  muscle  by  rendering  the  systole  more  complete  and 
prolonging  the  diastole.  By  its  action  the  pressure  in  the  coronary  arteries 
is  increased  and  more  time  is  allowed  for  their  filling.  It,  may  produce  per- 
manent benefit  by  reason  of  the  assistance  which  it  affords  in  the  production 
of  compensatory  hypertrophy.  The  constriction  of  the  peripheral  vessels 
caused  by  it  is  an  objection  to  its  use  but  this  may  not  be  sufficient  to  seriously 
interfere  with  the  increased  cardiac  power  secured,  and  even  if  this  is  the 
case,  this  effect  may  be  counteracted  by  drugs  which  have  an  opposite  action, 
such  as  the  nitrites;  the  exhibition  of  these  will  also  lessen  the  tendency  to  the 
exertion  of  the  so-called  cumulative  effect  of  digitalis.  The  particular  indi- 
cations for  the  administration  of  this  drug  are  a  rapidly  and  irregularly  acting 
heart,  low  tension  pulse  and  the  presence  of  venous  congestion.  In  mitral 
regurgitation  as  regards  the  employment  of  digitalis  we  may  divide  the  condi- 
tion into  three  groups :  i .  Those  in  which  the  left  ventricle  is  but  little  enlarged, 
while  the  nutrition  of  its  muscular  wall  is  well  preserved,  and  which  may  be 
attended  by  no  inconvenience  other  than  dyspnoea  (often  slight)  upon  exertion. 
2.  Those  with  oedema  of  greater  or  less  extent.  3.  Those  in  which,  with 
extensive  dilatation,  there  is  little  or  no  oedema  but  well-marked  pulmonary 
congestion.  By  increasing  the  force  of  the  contraction  of  the  left  ventricle 
an  approximation  of  the  mitral  cusps  is  caused  which  reduces  the  amount 
of  the  regurgitation  and  diminishes  the  venous  congestion.  Under  the  action 
of  the  drug  the  increased  force  of  the  systole  will  throw  proportionately  more 
blood  through  the  aortic  orifice  than  tlirough  the  partly  open  and  obstructed 
mitral  valve,  and  the  large  orifice  eventually  gaining  on  the  smaller,  more 
blood  will  pass  into  the  general  circulation  and  the  pulmonic  vessels  will  be 
relieved.  The  lengthened  diastole  will  also  be  of  service  in  allowing  more 
time  for  the  blood  to  flow  into  the  left  ventricle.  Thus  both  auricles  and 
ventricles  gain  increased  power  to  empty  themselves  and  the  longer  intervals 
between  pulsations  enable  the  former  to  more  completely  discharge  their 
contents  into  the  ventricles.  The  general  improvement  in  the  circulation 
caused  by  the  drug  has  an  excellent  effect  in  relieving  the  cardiac  pain  and 
distress  and  the  dyspnoea  and  cyanosis,  and  the  more  dropsy  characterizes 
the  condition  the  more  efficient  will  the  drug  prove. 

One  of  the  most  prompt  results  of  its  administration  is  a  marked  increase 
in  the  quantity  of  urine,  hence  it  is  of  essential  service  in  relieving  cardiac 
dropsy;  here  it  not  only  regulates  the  circulation  and  causes  evacuation  of  the 
surplus  fluid  through  the  kidneys,  but  also  acts  directly  on  the  vessels  by 


592  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

increasing  vaso-motor  force.  In  some  instances  the  diuretic  effect  of  digitalis 
is  materially  assisted  by  its  combination  with  an  alkaline  diuretic  such  as 
potassium  bitartrate  or  citrate  and  occasionally  it  may  be  found  that  diuresis 
can  be  established  only  after  free  purgation.  When  sleeplessness  is  a  marked 
symptom  it  is  due  to  the  non-maintenance  of  the  relationship  between  the 
cerebral  vessels  and  the  general  circulation — by  restoring  this  balance  digitalis 
enables  the  patient  to  sleep.  Dyspnoea  is  relieved  by  the  action  of  the  drug 
in  establishing  a  more  eflacient  pulmonary  circulation.  By  improving  the 
venous  flow  toward  the  heart  it  will  be  of  service  in  counteracting  the  venous 
engorgement  and  oedema  of  the  lungs,  the  right  heart,  the  liver,  the  kidneys, 
and  the  subcutaneous  tissues,  so  frequently  observed. 

In  some  patients  with  mitral  regurgitation  digitalis  may  seem  to  be  indicated 
and  yet  prove  injurious  rather  than  beneficial;  this  may  be  due,  in  part  at 
least,  to  its  causing  too  great  a  strain  upon  the  auricle,  since  with  a  very  patu- 
lous mitral  valve  the  blood  is  readily  backed  upon  the  auricle,  and  this,  being 
already  too  weak  for  the  ventricle,  is  unable  to  withstand  the  strain  imposed 
upon  it  by  the  stimulated  ventricle.  Conversely  to  the  previously  made 
statement,  the  less  closely  a  case  of  mitral  regurgitation  approaches  the 
oedematous  type,  the  less  the  benefit  which  is  likely  to  be  derived  from  digitalis 
in  it. 

In  most  instances  of  mitral  obstruction  the  same  benefit  will  accrue  from 
the  administration  of  digitalis  as  in  mitral  regurgitation,  the  increased  resist- 
ance here  leads  to  the  same  general  results  as  in  the  leakage  of  mitral  insuflS- 
ciency  and  like  the  latter  these  can  be  successfully  combated  by  the  strength- 
ening effect  of  the  drug  upon  the  heart-beat.  The  resulting  lengthening  of 
the  diastole  will  allow  more  time  for  the  auricle,  the  contracting  power  of 
which  is  at  the  same  time  increased,  to  empty  itself  into  the  ventricle  through 
the  obstructed  orifice.  The  ventricle  thus  more  perfectly  filled  sends  more 
blood  into  the  systemic  circulation  and  the  circulation  is  further  improved 
by  the  stimulation  of  the  right  ventricle  induced  by  the  digitalis  which  affords 
it  greater  power  to  force  the  blood  through  the  lungs.  It  is  possible,  however, 
that  the  increased  work  of  the  right  ventricle,  combined  with  the  mitral 
obstruction,  may  produce  pulmonary  congestion  with  the  result  of  lessening 
the  oxygenation  of  the  blood  and  so  interfering  with  the  nutrition  of  the  heart, 
so  that  in  well-selected  cases  the  beneficial  effects  of  digitalis  exceed  in  great 
measure  any  possible  evil  ones.  The  general  amelioration  of  symptoms 
which  the  drug  will  bring  about  is  much  the  same  as  in  the  case  of  mitral 
insufficiency. 

In  diseases  of  the  aortic  valve  there  is  a  diversity  of  opinion  concerning 
the  advisability  of  giving  digitalis.  While  certain  observers  assert  that  its 
advantages  more  than  offset  its  disadvantages,  there  is  but  little  question 
that  the  drug  is  better  omitted  in  instances  of  aortic  insufficiency.     It  increases 


THE    TREATMENT    OF    VALVULAR    LESIONS.  593 

the  work  of  the  heart  and  the  prolonged  diastole  which  it  causes  favors  ihe 
return  of  blood  through  the  imperfectly  closed  orifice  and  exposes  the  ventric- 
ular wall  to  excessive  strain  so  that  there  is  danger  of  syncope.  In  aortic 
obstruction,  before  the  incidence  of  compensatory  hypertrophy,  it  may  prove 
of  service.  There  is  some  obstruction  to  the  outflow  of  blood  from  the  heart 
and  digitalis  will  increase  the  ventricular  force  so  that  it  may  overcome  the 
difficulty.  After  compensatory  hypertrophy  has  become  established  the 
drug  is  useless  and  its  administration  may  result  fatally;  but  when  aortic 
obstruction  leads  to  mitral  insufinciency  it  may  be  given  with  advantage. 
Likewise  in  aortic  insuflSciency,  when  complicated  by  relative  mitral  insuffi- 
ciency, when  there  is  considerable  dilatation  of  the  left  ventricle,  perhaps  of 
sudden  onset  and  associated  with  dyspnoea,  precordial  pain  and  anxiety,  the 
drug  may  be  given  with  beneficial  results.  While  digitalis  is  usually  contra- 
indicated  in  aortic  insufiiciency  especially  when  associated  with  aortic  obstruc- 
tion, yet  when  the  heart  muscle  fails  and  the  hj'pertrophy  is  not  compensatory 
it  is  useful,  but  here,  as  well  as  in  all  cases  of  aortic  disease,  its  effects  must 
be  very  carefully  watched. 

The  indication  for  giving  or  withholding  digitalis  in  valvular  disease  rests 
far  less  upon  the  particular  lesion  present  than  upon  the  results  of  this  defect 
upon  the  cardiac  wall.  A  knowledge  of  the  relation  of  the  heart  muscle  to 
the  work  required  of  it  in  any  individual  instance  is,  therefore,  much  more 
important  from  a  therapeutic  standpoint,  than  the  recognition  of  a  patholog- 
ical condition  of  the  valves.  It  may  be  stated  in  general  terms  that  digitalis 
is  of  special  value  in  all  conditions  in  which  dilatation  of  the  heart  cavities 
has  resulted  in  valvular  disease  from  failure  of  the  muscular  wall. 

In  tricuspid  lesions,  both  obstruction  and  insufficiency,  digitalis  is  useful 
in  the  same  manner  as  in  mitral  disease  and  particularly  so  in  insuflBciency 
associated  with  dilatation  of  the  right  ventricle;  as  a  rule,  however,  the  bene- 
ficial results  are  less  marked  than  in  mitral  defects  and  as  in  the  latter  the 
rational  signs  usually  furnish  clearer  indications  for  the  employment  of  the 
drug  than  do  the  physical.  Thus,  it  is  indicated  when  the  pulse  is  rapid 
and  feeble  and  the  pulse  tension  low,  and  when  cough,  dyspnoea,  pulsation  of 
the  jugular  veins,  cyanosis,  scanty  urine  and  anasarca  are  present. 

Constriction  of  the  peripheral  vessels,  which  is  one  of  the  chief  physiological 
effects  of  digitalis,  is  often  so  marked  as  to  interfere  materially  with  the  suc- 
cessful use  of  the  drug  in  cardiac  disease.  Here  it  should  be  given  in  asso- 
ciation with  remedies  which  cause  dilatation  of  the  vessels,  such  as  the 
nitrites;  of  these  glyceryl  nitrate  enjoys  the  greatest  vogue  but  as  its  effects 
last  but  a  short  time  in  comparison  with  those  of  digitalis  it  should  be  given 
more  frequently,  usually  six  to  eight  times  daily;  its  dosage  should  be  meas- 
ured by  the  effect  obtained  but  is  generally  from  y^g-  to  -5^  of  a  grain  (0.0006 
to  0.0012).  Sodium  nitrite — dose  5  grains  (0.33) — may  also  be  employed 
38 


594  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

but  it  is  difficult  to  obtain  in  a  pure  state,  being  usually  contaminated  with 
the  nitrates.  Better  than  either  is  erythrol  tetranitrate;  this  drug  is  less  used 
than  its  merits  deserve  and  there  is  little  question  that  for  constant  employ- 
ment it  is  superior  to  the  more  evanescent  glyceryl  nitrate  and  the  somewhat 
uncertain  sodium  nitrite.  Its  dose  is  from  xV  to  J  a  grain  (0.006  to  0.032) 
and  in  compounding  it  its  explosive  properties  should  be  remembered.  It  is 
best  administered  in  pill  form  with  kaolin  as  an  excipient.  To  return  to 
digitalis,  since  it  acts  very  slowly  and  maintains  its  effect  for  a  long  time,  it 
is  often  sufficient,  after  the  primary  effects  have  been  obtained,  to  administer 
it  but  once  a  day,  for  the  purpose  of  continuing  its  influence. 

With  regard  to  the  value  of  the  different  preparations  of  the  drug  those 
most  used  are  the  tincture — dose  15  drops  (i.o) — and  the  infusion — dose  2 
drachms  (8.0);  the  latter  being  particularly  indicated  when  a  diuretic  effect 
is  desired  and  it  is  said  to  be  less  disturbing  to  the  stomach  than  the  tincture 
or  the  fluidextract  which  last  enjoys  considerable  vogue  among  certain  thera- 
peutists; its  usual  dose  is  i  minim  (0.065).  Wlien  it  is  desirable  to  give  the 
drug  hypodermatically  digitalin  el  to  3V  of  a  grain  (o.ooi  to  0.002)  may 
be  employed. 

Of  the  drugs  which  may  be  substituted  for  digitalis  strophanthus  deserves 
first  mention.  It  possesses  several  advantages  over  the  former,  namely: 
(i)  greater  rapidity  of  action,  modifying  the  pulse  rate  within  an  hour;  (2) 
less  marked  vaso-constrictor  effect;  (3)  greater  diuretic  powers;  (4)  no  diges- 
tive disturbance  from  properly  made  preparations;  (5)  absence  of  cumula- 
tive effect;  (6)  greater  value  in  children,  whose  vasodilators  are  easily  affected; 
and  (7)  greater  safety  in  the  aged  in  whom  the  vaso-constriction  is  often  present 
primarily.  The  especial  indications  for  the  employment  of  strophanthus 
are:  i.  Rapidly  recurring  cardiac  systoles  of  lessened  force  and  irregular 
rhythm.  Here  we  get,  first,  a  more  vigorous  ventricular  contraction  with 
slowing  of  the  pulse  rate  and  a  consequent  lengthening  of  the  diastole,  which 
is  the  period  of  rest  for  the  heart,  next  the  irregularity  disappears,  and  lastly, 
from  improved  nutrition  of  the  heart  we  obtain  a  permanent  strengthen- 
ing of  its  muscle.  2.  The  comparative  insignificance  of  the  vaso-motor 
effects  permits  the  use  of  the  drug  in  those  instances  of  permanent  high  tension 
which  are  met  in  some  forms  of  nephritis  and  in  the  rigid  arteries  of  the  aged. 
3.  Whenever  diuresis  can  be  promoted  by  increased  blood  tension  resulting 
from  more  vigorous  cardiac  contractions  this  may  be  expected  from  the  employ- 
ment of  strophanthus.  4.  The  rapidly  appearing  effects  of  its  adminis- 
tration, together  with  its  regular  elimination,  make  it  the  drug  of  choice  when 
the  symptoms  are  urgent.  5.  The  absence  of  digestive  disturbances 
from  therapeutic  doses  and  slight  likelihood  of  habituation  make  it  important 
when  long-continued  use  is  necessary.  It  should,  therefore,  be  the  remedy 
of  choice  in  all  patients,  (i)  in  whom  we  wish  to  establish  compensation;  (2) 


THE    TREATMENT    OF    VALVULAR    LESIONS.  595 

of  arterial  degeneration  when  more  energetic  cardiac  contraction  is  required; 
(3)  of  cardiac  disease  when  a  diuretic  is  necessary;  (4)  of  weak  or  irritable 
heart  action;  (5)  of  cardiac  disease  in  childhood  or  old  age.  Failure  will 
follow  its  administration  in:  (i)  advanced  degeneration  of  the  heart  muscle; 
(2)  extreme  mechanical  obstruction  to  the  circulation  from  valvular  insuffi- 
ciency or  obstruction;  and  (3)  a  combination  of  these.  The  drug  should  not 
be  employed  in  too  large  or  too  frequently  repeated  doses;  usually  a  dose  of 
5  minims  (0.33)  of  a  reliable  tincture  tliree  or,  possibly,  four  times  a  day  is 
sufficient.  Given  with  erythrol  tetranitrate  it  affords  absolute  control  of  the 
blood-vessels. 

Erythrophloeum  may  also  be  employed  as  a  substitute  for  digitalis.  Its 
effects  are  practically  the  same  but  it  is  rather  less  reliable.  Its  employment 
should  be  confined  to  instances  of  a  fairly  competent  heart  with  low  arterial 
tension  and  to  "those  cases  in  which  digitalis  has  lost  its  usefulness  or  has 
utterly  failed.     The  dose  of  the  tincture  is  from  5  to  10  minims  (0.33  to  0.66). 

Caffeine  is  chiefly  useful  in  heart  affections  in  cases  attended  with  dropsy 
where  by  its  marked  diuretic  action  it  is  often  very  efficacious;  it  may  often 
be  combined  with  digitalis,  strophanthus  and  other  heart  tonics.  When  given 
for  considerable  periods  it  may  produce  insomnia  or  even  marked  hallucina- 
tions similar  to  those  of  delirium  tremens;  its  usual  dose  is  from  i  to  3  grains 
(0.065  to  0.2),  or  it  may  be  administered  hypodermatically,  when  a  rapid 
effect  is  desired,  as  caffeine  sodio-benzoate,  of  which  the  dose  is  2  to  10  grains 
(0.13  to  0.66). 

Strychnine  is  a  reliable  cardiac  stimulant  in  instances  of  valvular  disease 
where  digitalis  is  contraindicated  and  may  be  often  combined  to  advantage 
with  other  heart  tonics,  such  as  caffeine.  When  there  is  imminent  danger 
of  failure  of  the  heart's  action,  and  especially  in  pulmonary  oedema,  this 
drug  administered  hypodermatically  in  large  and  frequently  repeated  doses 
very  often  is  of  the  greatest  service.  Here  as  much  as  yV  (0.003)  ^^  even 
To  of  a  grain  (0.006)  may  be  given  and  repeated  if  necessary,  but  as  soon  as 
muscular  twitchings  are  noticed  it  must  be  discontinued. 

Sparteine  sulphate  may  be  employed,  especially  when  diuresis  is  desired; 
its  dose  is  i  to  I  a  grain  (0.012  to  0.033)  and  it  is  also  said  to  be  valuable 
in  producing  regularity  of  the  heart  action.  It  quickens  the  beat  when  a 
weak,  atonic  state  is  present  and  is  quick  in  action.  On  the  whole  it  is  inferior 
to  digitalis,  but  is  not  cumulative  and  is  useful,  especially  m  uncompensated 
mitral  disease. 

Other  cardiac  stimulants  that  may  be  mentioned  are  adonidin,  convalleria 
and  cactus  grandiflorus.  The  first  of  these  possesses  the  same  indications 
as  digitalis;  it  is,  however,  less  serviceable  but  may  prove  a  satisfactory  sub- 
stitute when  the  latter  drug  is  contraindicated  or  fails.  Its  action  is  prompt 
and  it  is  often  valuable  in  beginning  the  regulation  of  the  cardiac  movements 


596  DISEASES    or    THE    HEART    AND    BLOOD-VESSELS. 

before  digitalis  has  had  time  to  take  effect.  Its  dose  is  ^  to  -j  of  a  grain  (o.oi 
to  0.02);  it  is  too  irritating  to  be  employed  hypodermatically.  Convalleria 
is  unreliable  in  its  effect  and  its  vaunted  selective  action  upon  the  right  heart 
is  probably  fictitious.  Its  indications  are  the  same  as  those  for  digitalis.  The 
dose  of  the  fluidextract  is  8  minims  (0.5).  Cactus  is  of  great  use  in  aortic 
insufi&ciency  but  is  absolutely  contraindicated  in  mitral  obstruction,  thus 
being  of  value  only  where  digitalis  is  inadmissible.  It  increases  both  the 
cardiac  force  and  rapidity,  being,  perhaps,  the  only  drug  which  possesses 
this  effect.  It  does  not  replace  other  cardiac  stimulants  but  is  useful  m  many 
instances  where  these  are  dangerous.  Cactus  is  active  only  when  carefully 
prepared  from  the  green  plant.  A  properly  made  fluidextract  is  of  a  peculiar 
opalescent-green  color;  if  brown  it  is  inert.  The  dose  is  from  10  to  30  minims 
(0.66  to  2.0). 

In  addition  to  the  administration  of  drugs  there  are  other  measures  by  which 
the  impeded  circulation  may  be  relieved.  Of  these  venesection  is  one  of 
the  most  effectual  and  is  particularly  indicated  in  mitral  obstruction  with 
pulmonary  congestion,  marked  dyspnoea  and  cyanosis  and  in  dilatation  with 
arteriosclerosis.  As  many  as  20  or  30  ounces  (600.0  to  900.0)  of  blood  may 
be  withdrawn.  Depletion  through  the  bowels  is  another  useful  method  of 
relieving  venous  congestion  and  may  be  well  carried  out  by  the  method  of 
Matthew  Hay  which  consists  of  the  administration  in  the  evening  of  2  ounces 
(60.0)  of  magnesium  sulphate  which  have  previously  been  dissolved  in  an 
equal  amount  of  boiling  water.  The  patient  should  take  nothing  to  drink 
before  the  noon  of  the  following  day  and  usually  before  this  time  he  will  have 
had  several  watery  stools  and  will  have  noticed  a  marked  increase  in  the 
quantity  of  urine.  The  exhibition  of  so  drastic  a  cathartic  as  the  above  is 
not  contraindicated  even  if  the  pulse  is  feeble  and  irregular. 

The  Schott  method  of  treatment  by  means  of  carbonic  acid  gas  baths  and 
resistance  exercises  is  useful  in  all  forms  of  loss  of  compensation.  For  a 
description  of  these  measures  the  reader  is  referred  to  p.  561. 

The  anasmia  which  is  so  frequent  an  accompaniment  of  cardiac  disease  neces- 
sitates the  routine  administration  of  iron  and  other  tonics,  especially  strychnine. 

The  Treatment  of  Special  Symptoms:  Dyspna'a.  This  S}'mptom  is  due 
to  insufficient  oxygenation  of  the  blood  in  the  lungs  as  a  result  of  the  conges- 
tion of  these  organs;  the  correction  of  the  pulmonary  engorgement  by  means 
of  the  remedies  suggested  above  will  often  relieve  the  shortness  of  breath; 
if  the  congestion  has  resulted  in  the  transfusion  of  serum  into  the  pleural 
cavities  these  should  be  aspirated  and  the  fluid  withdrawn.  Re-accumula- 
tions necessitate  repetition  of  the  operation.  Dyspnoea,  when  due  to  arterial 
contraction,  may  be  lessened  by  the  vaso-dilators  as  suggested  above.  In 
the  marked  nocturnal  dyspnoea  of  advanced  cardiac  disease  often  nothing 
but  morphine  will  afford  relief  although  the  compound  spirit  of  aether — i 


THE    TREATMENT    OF    VALVULAR    LESIONS.  597 

drachm  (4.) — repeated  if  necessary,  sulphonethylmethane  (trional), — gr.  x 
(0.66) — sulphonmethane  (sulphonal), — gr.  xx  (1.33) — diethylmalomylurea 
(veronal) — gr.  x  (0.66),  or  chloralformamide  (chloralamide) — gr.  xxx  (2.0), 
may  be  tried.  These  failing,  morphine  may  be  given  without  fear,  for  it 
has  a  distinctly  cardiac  stimulant  eiifect,  in  dose  of  j  of  a  grain  (0.016)  either 
subcutaneously  or  by  mouth.     Inhalations  of  oxygen  may  give  relief. 

Palpitation  and  Precordial  Distress.  In  addition  to  the  heart  stimulants 
discussed  above  we  may  employ  locally  the  ice  coil,  a  belladonna  plaster, 
a  closely  watched  nitric  acid  issue  or  other  blister.  The  combination  of 
potassium  iodide  or  glyceryl  nitrate  and  belladonna  with  digitalis  is  often 
effectual  and  when  the  heart  is  markedly  over-active,  turbulent  and  irregular, 
the  tincture  of  aconite  in  doses  of  5  or  10  minims  (0.33  to  0.66)  every  hour 
often  produces  excellent  results.  This  drug  should  be  carefully  watched  and 
discontinued  as  soon  as  the  condition  is  relieved  or  untoward  effects  are  noted. 
Palpitation  and  oppression  due  to  gastric  and  intestinal  distention  necessitate 
the  exhibition  of  laxatives  and  intestinal  antiseptics. 

(Edema.  In  addition  to  the  measures  already  described  for  relief  of  the 
general  venous  congestion,  particularly  the  administration  of  digitalis,  stroph- 
anthus  and  caffeine  which  are  diuretics,  and  glyceryl  nitrate  and  erythrol 
tetranitrate  which  increase  the  blood  supply  of  the  kidney  by  dilating  the  renal 
artery,  together  with  depletion  by  means  of  hydrogogue  cathartics,  such  as 
elaterin  and  jalap,  and  Hay's  method,  we  have  other  means  at  our  disposal. 
The  increase  in  the  action  of  the  kidneys  following  the  employment  of  copious 
high  rectal  irrigations  of  hot  normal  saline  solution  at  116°  to  120°  F.  (46.5° 
to  49°  C.)  is  often  very  marked  and  this  simple  procedure  may  be  repeated 
several  times  daily  if  necessary.  The  Guy's  diuretic  piU  consisting  of  i  grain 
(0.065)  each  of  powdered  digitalis,  squill  and  calomel,  given  every  four  or  six 
hours  for  two  or  three  doses  and  theobromine  sodio-salicylate,  i  to  2  drachms 
(4.0  to  8.0)  have  been  used  with  benefit.  (Edema  of  the  legs  may  be  lessened 
by  the  recumbent  position  or  by  bandaging.  In  extreme  instances  scarifica- 
tion may  become  necessary;  this  should  be  done  under  the  strictest  antiseptic 
precautions  as  should  abdominal  paracentesis,  which  is  indicated  in  marked 
degrees  of  ascites.  The  management  of  hydrothorax  has  already  been  con- 
sidered. The  treatment  of  dropsical  conditions  by  means  of  decloridation 
will  be  discussed  in  the  section  upon  renal  diseases. 

The  insomnia  which  is  frequently  a  source  of  great  discomfort  to  the  patient 
may  be  relieved  in  milder  instances  by  a  drachm  (4.0)  of  the  compound  spirit 
of  aether  or  a  half  drachm  (2.0)  of  paraldehyde  or  of  amylene  hydrate  taken 
on  retiring.  The  great  disadvantage  of  all  these  is  their  unpleasant  taste 
and  the  fact  that  the  two  first  produce  disagreeable  eructations.  Sulphon- 
methane (sulphonal),  sulphonethylmethane  (trional)  and  veronal  may  prove 
useful  and  it  may  become  necessary  to  place  our  dependence  upon  morphine. 


598  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

With  regard  to  diet  no  very  fixed  rules  can  be  laid  down.  During  the 
absence  of  compensation  the  regimen  should  be  of  the  lightest  and  consist 
chiefly  of  milk,  the  meat  broths  and  extracts  and  soft  eggs.  Carbohydrate 
foods  should  be  given  with  caution  on  account  of  their  proneness  to  cause 
flatulence.  Should  the  stomach  become  disturbed  and  nausea  and  vomiting 
supervene  these  may  be  relieved  by  a  greater  restriction  of  the  diet.  Milk 
with  lime  water  or  vichy  may  be  given;  bits  of  cracked  ice  and  small  quan- 
tities of  iced  champagne  are  frequently  useful.  The  addition  of  10  grains 
(0.66)  of  cerium  oxalate  and  20  grains  (1.33)  of  sodium  bicarbonate  to  each 
glass  of  milk  will  sometimes  relieve  nausea.  Upon  the  re-establishment  of 
compensation  a  gradual  return  to  a  more  generous  diet,  which  may  include 
fish,  scraped  beef,  the  white  meat  of  poultry  and  other  like  articles,  should 
be  allowed. 

The  treatment  oj  congenital  heart  disease  differs  in  no  essential  from  that  of 
acquired  cardiac  defects;  the  measures  discussed  above  should,  however, 
be  so  regulated  as  to  render  them  applicable  to  children. 

THE  NEUROSES  OF  THE  HEART. 
PALPITATION. 

Definition.  An  abnormally  rapid  action  of  the  heart,  not  associated  with 
evidence  of  organic  lesion,  but  of  which  the  patient  is  conscious  and  which 
may  be  regular  or  irregular.  Murmurs  due  to  functional  disorders  may  be 
present  especially  if  anaemia  is  co-existent. 

.etiology.  The  condition  is  more  common  in  the  female  sex  and  is  very 
frequently  observed  at  the  incidence  of  puberty,  at  the  menstrual  epoch 
and  at  the  menopause.  All  the  causes  contributing  to  the  neurasthenic  or 
the  hysteric  state  may  be  named  as  aetiological  factors,  such  as  mental  over- 
work and  emotion,  uterine  and  gastric  disorders,  anaemia  and  the  physical 
weakness  induced  by  over -work  or  long  illness. 

A  frequent  cause  is  the  abuse  of  alcohol,  tea,  coffee,  or  tobacco.  The 
so-called  "irritable  heart"  described  by  Da  Costa  as  occurring  in  the  soldiers 
engaged  in  the  Civil  War  was  associated  with  neiurotic  palpitation  but  to  its 
causation  there  were  other  contributory  factors  such  as  mental  anxiety, 
physical  over-work  and  weakness  due  to  iUness.  With  the  palpitation  in 
these  patients  dilatation  was  probably  often  associated. 

Symptoms.  Of  these  the  consciousness  of  the  heart's  action  is  the  most 
prominent.  The  discomfort  may  be  merely  an  evanescent  fluttering  accom- 
panied by  merely  slight  discomfort,  or  the  action  of  the  organ  may  be  greatly 
accelerated,  irregular  and  markedly  increased  in  force.  This  manifestation 
lasts  varying  periods  of  time,  occurring  often  in  paroxysms  {paroxysmal  tacky- 


TACHYCARDIA  AND  BRADYCARDIA,  599 

cardia)  and  may  be  associated  with  a  sense  of  weakness  or  with  nausea,  flushing 
or  paleness  of  the  face  and  an  increased  urinary  excretion.  An  attack  may 
be  induced  by  exertion. 

Physical  examination  of  the  heart  reveals  little  except  the  increased  rate 
of  its  pulsations;  the  heart  sounds  may  be  sharp  and  distinct  or  impure;  there 
may  be  accentuation  of  the  pulmonic  or  aortic  sounds.  Ventriculo-systolic 
murmurs  may  be  present,  heard  usually  at  the  base  but  sometimes  at  the 
apex. 

The  diagnosis  is  based  upon  the  intermittency  of  the  attacks,  the  co-exist- 
ent neurotic  element  or  anaemia  and  the  fact  that  the  condition  is  met  in 
young  individuals  as  a  rule. 

The  prognosis  as  to  life  is  favorable  although  the  condition  itself  may 
present  difficulties  as  to  its  removal. 

TACHYCARDIA  AND  BRADYCARDIA. 

Tachycardia  or  rapid  heart  may  be  a  normal  condition,  individuals  having 
been  observed  in  whom  the  pulse-rate  in  perfect  health  was  100  or  over. 
Paroxysmal  tachycardia  is  a  condition  in  which  spasmodic  increase  in  the 
pulse-rate  takes  place  at  intervals  and  without  assignable  cause.  The  parox- 
ysms last  from  only  a  few  moments  to  several  hours  and  may  occur  at  varying 
intervals.     The  cardiac  pulsations  may  reach  200  to  220  per  minute. 

Bradycardia  or  slow  heart  also  may  be  a  normal  condition,  many  persons 
having  in  health  a  pulse  much  lower  than  the  normal  72;  a  rate  of  from  50 
to  60  is  not  unusual  and  instances  of  much  lower  pulse  have  been  reported. 
Care  should  be  taken  to  make  sure  that  the  radial  impulses  correspond  in 
number  to  the  apical  impulses,  since  it  is  not  infrequent  in  certain  cardiac 
conditions  for  the  alternate  systole  to  be  too  weak  to  send  an  impulse  to  the 
periphery.  Slowness  of  the  pulse  may  be  observed  during  pregnancy  and  is  a 
natural  consequence  of  hunger  and  senility. 

Bradycardia  has  been  noted  as  a  pathological  entity  in  (a)  convalescence 
after  the  acute  infectious  diseases;  (b)  dyspepsia,  jaundice,  gastric  ulcer  and 
cancer;  (c)  pulmonary  diseases,  rarely;  (d)  circulatory  diseases,  particularly 
those  affecting  the  cardiac  muscle  and  in  connection  with  deficient  supply 
of  blood  in  the  coronary  circulation;  (e)  nephritis;  (f)  toxaemia  from  uraemia, 
lead,  alcohol,  coffee  and  digitalis;  (g)  constitutional  diseases  such  as  gout,  anae- 
mia and  diabetes;  (h)  nervous  diseases,  apoplexy,  neoplasms,  affections  of  the 
medulla  and  cervical  cord,  epilepsy,  general  paralysis,  etc.;  (i)  genito-urinary 
and  cutaneous  diseases. 

Bradycardia  is  the  result  of  irritation  of  the  center  of  origin  of  the  vagus  or 
of  its  peripheral  portion;  it  also  may  be  caused  by  a  condition  of  exhaustion 
of  the  cardio-motor  apparatus. 


6oO  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

The  Adams-Stokes  syndrome  is  a  variety  of  bradycardia  sometimes 
transient  but  usually  permanent  and  associated  with  attacks  of  dizziness 
or  even  convulsions  and  unconsciousness.  Dyspnoea  and  perhaps  Cheyne- 
Stokes  respiration  are  frequently  associated  symptoms.  It  is  met  with  in 
old  subjects  with  arteriosclerosis,  in  myocarditis  of  syphilitic  origin  and  may 
occur  as  a  neurosis.  The  pulse-rate  may  fall  even  to  20  or  10  per  minute. 
In  neurotic  patients  it  is  not  a  serious  condition  but  in  its  other  forms  the 
prognosis  is  less  favorable  although  death  may  not  supervene  for  years.  It  is 
the  result  of  affections  of  the  pneumogastric  nerves,  of  the  medulla  oblongata, 
and  of  disease  of  the  inter- ventricular  septum  which  causes  a  disordered  action 
of  the  auriculo-ventricular  bundle  of  His,  a  group  of  muscle  fibres  which  has 
its  origin  in  the  inter-auricular  septum  below  the  foramen  ovale  and  passes 
downward  and  anteriorly  to  the  junction  of  the  auricles  with  the  ventricles, 
where  it  is  in  close  approximation  to  the  mesial  cusp  of  the  tricuspid  valve, 
and  finally  ends  just  below  the  origin  of  the  aorta. 

Under  the  term  heart  block  a  condition  has  been  described  which  is  char- 
acterized by  failure  of  the  ventricle  to  follow  each  auricular  contraction,  in 
other  words  the  auricular  systole  takes  place  more  often  than  does  the  ven- 
tricular contraction.  This  peculiarity  is  believed  to  be  due  to  an  affection 
(a)  of  the  ventricular  wall,  (b)  of  the  pneumogastric  nerve,  or  (c)  of  the  con- 
nection between  the  auricle  and  ventricle. 

ARRHYTHMIA. 

Cardiac  arrhythmia  or  irregular  pulse  may  occur  in  various  forms:  (a) 
Irregularity  in  time  in  which  an  occasional  beat  is  omitted;  this  omission 
may  occur  at  irregular  intervals  or  more  rarely  it  may  appear  as  a  regular 
irregularity  in  which  every  second,  fourth,  sixth,  etc.,  beat  is  lost.  In  other 
instances  the  so-called  pidsiis  higeminus  or  trigeminus  may  be  observed  in 
which  two  or  three  beats  closely  succeed  one  another  to  be  followed  after 
an  interval  by  a  repetition  of  the  phenomenon.  These  often  occur  with 
mitral  disease,  (b)  Irregularity  in  force;  here  the  rate  is  regular  but  the 
strength  of  the  pulsations  is  unequal  and  consequently  an  alteration  in  volume 
is  frequently  co-existent,  (c)  Irregularity  of  force  and  frequency  may  occur 
in  combination. 

Rarer  varieties  of  cardiac  arrhythmia  are  the  pidsiis  paradoxus  described 
by  Kiissmaul  which  is  characterized  by  an  increase  of  rate  and  a  decrease  in 
force  during  inspiration.  It  is  observed  in  chronic  pericardial  adhesions, 
pleuro-pericardial  adhesions,  compression  of  the  aorta  and  in  weak  heart 
action  due  to  any  cause;  the  gallop  rhythm  in  which  the  sounds  occur  in  threes 
and  resemble  in  time  the  sounds  made  by  the  foot  fall  of  a  horse  at  a  canter; 
this   is  met  in  the  cardiac   hypertrophy  of  arteriosclerosis  and  nephritis,  in 


THE    TREATMENT    OF    PALPITATION    AND    TACHYCARDIA.  6oi 

certain  forms  of  myocardial  degeneration  and  extreme  anaemia;  emhryocardia 
in  which  the  first  sound  closely  resembles  the  second,  as  in  the  foetal  heart. 
This  occurs  in  extremes  of  dilatation  and  in  the  cardiac  weakness  of  the  later 
stages  of  the  severer  infectious  diseases.  Delirium  cordis  is  the  most  extreme 
type  of  cardiac  irregularity;  both  force  and  frequency  are  affected  and  the 
condition  may  be  seen  in  extraordinary  t}'pes  of  dilatation  and  of  severe  exoph- 
thalmic goitre. 

.Etiology.  Arrhythmia  occurs  as  a  result  of  (a)  cerebral  influences,  both 
organic,  as  in  haemorrhage  or  concussion,  and  functional;  (b)  reflex  disorders 
of  the  circulation  caused  by  associated  digestive,  pulmonary  and  renal  afifec- 
tions;  (c)  the  influence  of  poisons  such  as  tobacco,  tea,  coffee  and  various 
drugs;  (d)  cardiac  changes  which  may  affect  either  the  innervation  of  the 
organ  or  its  muscular  structure. 

Symptoms.  Cardiac  irregularity  in  many  instances  is  accompanied  by  no 
symptoms  and  may  be  detected  by  accident.  In  other  instances  the  patient 
may  be  conscious  of  the  condition  and  annoyed  by  it  even  though  it  interferes 
in  no  way  with  his  routine  of  life.  In  subjects  in  whom  it  occurs  as  a  result 
of  cardiac  weakness  or  disease  it  is  associated  with  the  other  manifestations 
of  these  conditions. 

The  diagnosis  can  be  readily  made  by  the  careful  routine  methods  of  phys- 
ical examination  of  the  heart  and  pulse.  When  the  condition  is  not  organic 
this  fact  can  be  ascertained  from  the  history  and  consideration  of  the  symp- 
toms and  physical  signs. 

The  prognosis  is  in  many  instances  most  favorable,  functional  irregularity 
not  being  prejudicial  to  health;  the  outlook  is  much  more  dubious  when  disease 
of  the  arteries  or  of  the  heart  muscle  is  present. 


The  Treatment  of  Palpitation  and  Tachycardia. 

The  same  means  are  applicable  to  both  these  conditions.  Recognition 
of  the  cause  is,  of  course,  necessary,  and  this  should  receive  appropriate  treat- 
ment. When  due  to  hysteria  or  neurasthenia  the  management  of  the  cardiac 
condition  is  primarily  that  of  the  nervous  condition;  anaemia,  digestive  dis- 
orders, uterine  affections,  etc.,  should  be  corrected.  Sexual  excitement,  tea, 
coffee  and  tobacco  should  be  prohibited  and  a  life  free  from  worry  and  from 
physical  over-exertion  should  be  enjoined.  In  certain  instances  a  course  of 
treatment  by  means  of  carbonic  acid  gas  baths  and  resistance  exercises  is 
very  beneficial  and  the  Weir  Alitchell  cure  is  strongly  indicated  in  neuras- 
thenic and  hysteric  patients  when  practicable.  The  application  of  the  gal- 
vanic current  to  the  vagus  has  been  suggested;  the  positive  pole  should  be 
placed  under  the  angle  of  the  mandible  and  the  negative  lower  in  the  neck  or 


6o2  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

over  the  sternum.  Only  a  weak  current  should  be  used  and  this  but  for  a 
few  minutes  only.  Electricity,  it  should  not  be  forgotten,  is  often  dangerous 
and  a  strong  current  may  cause  stoppage  of  the  heart's  action. 

During  the  paroxysm  the  patient  should  be  put  completely  at  rest,  prefer- 
ably in  bed,  although,  if  dyspnoea  is  present,  the  shoulders  may  be  elevated. 
Quiet  should  be  enjoined  and  all  disturbing  influences  should  be  avoided. 
The  over-acting  heart  may  be  calmed  by  the  application  of  the  ice  coil  to  the 
precordium  and  in  connection  with  this,  frequent  drinking  of  cold  water  or 
holding  of  bits  of  ice  in  the  mouth  is  recommended.  At  the  beginning  of  an 
attack,  as  an  abortive  measure,  we  may  rub  in  an  ointment  made  as  follows: 
I^  veratrinae,  gr.  iii  (0.2);  extracti  opii,  gr.  xv  (i.o);  olei  terebinthinae,  nxi 
(0.065);  olei  menthae  piperitae,  rrLXV  (i.o);  adipis  benzoinati,  q.s.  ad  §i  (30.0). 
Misce  et  signa  external  use.  When  the  heart  action  is  markedly  rapid 
aconite  or  veratrum  viride  may  be  employed  and  in  neurotic  subjects  the 
bromides  and  the  antispasmodics  are  beneficial.  The  following  formulae 
may  be  found  useful.  I^  camphorae  monobromatas,  gr.  ii  (0.13);  zinci  valer- 
atis,  gr.  i  (0.065);  extracti  hyoscyami,  gr.  ss  (0.033).  Fiat  pilula  numero  i. 
Signa  one  pill  every  4  hours.  I^  tincturae  veratri,  §ss  (15.0);  aquas  destilla- 
tae,  syrupi  aurantii,  aa  q.s.  ad  §iv  (120.0).  Misce  et  signa  one  teaspoonful 
three  or  four  times  a  day.  When  precordial  distress  is  marked  it  may  be  relieved 
by  a  mixture  containing  tincture  of  veratrum,  oss  (15.0);  Hoffmann's  an- 
odyne, oiss  (45.0);  codeine,  gr.  v  (0.33);  compound  tincture  of  cardamom 
to  oiv  (120.0).  If  anaemia  is  present  we  may  employ  iron  and  arsenic. 
DigitaHs  should  be  given  with  discrimination  and  in  obstinate  instances  of 
palpitation  with  weak,  frequent  and  irregular  pulse.  In  very  severe  cases  the 
use  of  morphine  in  \  grain  (0.016)  doses  may  become  necessary. 

The  Treatment  of  Bradycardia. 

In  managing  this  condition  the  primary  cardiac  affection,  if  detected, 
should  receive  appropriate  treatment.  Concurrent  arteriosclerosis  should 
also  be  given  attention.  Digitalis  should  not  be  employed  in  fatty  heart  but 
in  obstinate  instances  of  bradycardia,  if  the  pulse  rate  is  not  below  50,  small 
doses  may  be  given  with  benefit  in  some  instances.  The  patient's  general 
condition  should  be  attended  to  and  proper  diet  and  mode  of  life  enjoined;, 
the  bowels  should  be  kept  open  and  all  disturbances  of  digestion  avoided  in 
so  far  as  possible.  The  attacks  necessitate  confinement  to  bed  and  the  dif- 
fusible cardiac  stimulants,  alcohol,  ammonia,  etc.,  should  be  prescribed. 
Inhalations  of  amyl  nitrite  are  suggested  if  there  is  tendency  to  arteriosclerosis 
and  arterial  contraction.  Glyceryl  nitrate  (nitroglycerin)  and  strychnine 
are  also  useful  and  the  administration  of  caffeine  either  by  mouth  or  hypoder- 


THE    TREATMENT    OF    ARRHYTHMIA.  603 

matically  is  recommended  where  the  condition  is  due  to  lack  of  blood  supply 
in  the  medulla.  The  following  formula  may  be  prescribed  to  advantage: 
I^  caffeina?  sodio-benzoatis,  gr.  xx  (1.33);  sparteinae  sulphatis,  gr.  iii  (0.2); 
aquae  destillatae,  syrupi  aurantii,  aa  q.s.  ad  5iv  (120.0).  Misce  et  signa  one 
teaspoonful  (4.0)  thrice  daily.  In  the  bradycardia  of  uraemia  pilocarpine  hy- 
drochloride combined  with  alcohol  is  useful.  The  former  when  carefully 
watched,  and  its  depressing  effect  counteracted  by  alcohol,  may  be  given  in 
divided  doses  up  to  i  or  2  grains  (0.065-0.13)  daily. 

The  Adams-Stokes  syndrome  is  very  difficult  of  treatment.  The  patient's 
general  condition  should  be  cared  for  and  the  digestion  should  receive  partic- 
ular attention.  The  diffusible  stimulants  may  prove  of  benefit  but  are  often 
disappointing;  the  inhalation  of  oxygen  for  a  time  each  day,  the  hypoder- 
matic administration  of  morphine  and  the  employment  of  digitalis  have  all 
acted  well  in  certain  instances  but  as  a  rule  produce  but  indifferent  results. 
The  same  is  true  of  glyceryl  nitrate.  A  patient  reported  by  Stokes  was  able 
to  abort  or  to  lessen  the  severity  of  an  attack  by  placing  himself  on  his  hands 
and  knees  and  hanging  his  head  as  low  as  possible;  supposedly  relief  was 
brought  about  by  increasing  the  cerebral  blood  supply. 

The  Treatment  of  Arrhythmia. 

The  treatment  of  the  disordered  rhythm  of  chronic  endocarditis  is  com- 
prised in  the  treatment  of  the  causative  affection.  The  cerebral  conditions 
which  cause  irregular  heart  action  are  difficult  to  influence  but  the  instances 
due  to  renal,  digestive  and  pulmonary  abnormalities  may  be  benefited  by 
the  proper  management  of  the  primary  condition.  The  general  treatment 
of  cardiac  arrhythmia  consists  in  forbidding  tobacco,  tea,  and  coffee,  regu- 
lating the  diet  and  mode  of  life  and  if  the  symptom  is  associated  with  palpi- 
tation, tachycardia  or  bradycardia,  the  employment  of  the  means  suggested 
above  for  the  amelioration  of  these  affections. 

ANGINA  PECTORIS. 

Synonym.     Stenocardia. 

Definition.  A  symptom  of  various  lesions  of  the  heart  and  blood-vessels 
characterized  by  paroxysms  of  severe  pain  referred  to  the  heart  and  to  the 
neck,  shoulders  and  even  down  the  arms.  The  attack  is  often  accompanied 
by  dyspnoea  and  in  very  marked  instances  by  a  sense  of  impending  death. 

Etiology.  The  condition  is  confined  almost  exclusively  to  adult  males, 
heredity  seems  to  have  a  certain  influence  in  its  causation  and  gout,  diabetes 
and  influenza  may  be  mentioned  as  predisposing  factors.     Anginal  attacks 


6o4  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

may  occur  in  endocardial  lesions,  particularly  those  affecting  the  aortic  valve, 
in  adhesive  pericarditis,  syphilitic  disease  of  the  aorta,  and  during  the  develop- 
ment of  aortic  aneurysm. 

As  exciting  causes  of  the  paroxysm  sudden  mental  or  physical  over-exertion, 
sudden  exposure  to  cold  and  distention  of  the  stomach  by  food  or  gas  may 
be  mentioned. 

Various  theories  have  been  advanced  to  explain  the  occurrence  of  the  attack 
and  of  these  the  most  generally  accepted  is  that  it  is  the  result  of  a  temporary 
diminution  of  the  blood  supply  of  the  cardiac  muscle  due  to  sudden  contrac- 
tion or  to  disease  of  the  coronary  arteries,  or  affections  of  the  neighboring 
structures  which  interfere  with  the  free  passage  of  blood  through  them.  Other 
explanations  of  the  symptom  are  that  it  is  due  to  a  spasm  of  the  vaso- motor 
nerves  of  the  heart,  to  a  spasm  of  the  heart  muscle,  to  neuralgia  of  the  cardiac 
nerves,  and  that  it  is  a  functional  neurosis. 

Pathology.  The  most  constant  change  found  post  mortem  is  an  athe- 
romatous condition  of  the  coronary  arteries  and  of  the  first  part  of  the  aorta; 
with  these  general  arteriosclerosis  and  myocardial  degeneration  are  frequently 
associated.  By  no  means  all  instances  of  coronary  arteriosclerosis  are  char- 
acterized by  attacks  of  angina  pectoris. 

Symptoms.  The  paroxysm  is  characterized  by  the  sudden  onset,  during 
unusual  exertion  or  excitement,  of  an  agonizing  pain,  usually  referred  to 
the  middle  or  back  of  the  sternum,  (Beaumes's  sign),  but  radiating  to  the 
arms,  more  often  the  left,  or  even  to  the  abdomen  or  pelvis  or  down  the  leg. 
There  is  an  accompanying  sensation  of  constriction  of  the  chest  and  dyspnoea. 
The  facies  expresses  the  agony  which  the  patient  is  experiencing,  it  is  pallid 
or  ashy  and  may  be  moist  with  perspiration ;  there  is  great  restlessness  and 
anxiety.  The  heart  action  may  be  unaffected,  accelerated  or  retarded,  the 
pulse  tension  is  usually  increased.  The  sense  of  impending  death  is  not 
always  present.  The  attack  may  last  but  a  few  moments  or  may  be  pro- 
longed to  half  an  hour;  as  it  passes  off  the  patient  is  left  in  a  state  of  weak- 
ness and  he  may  belch  a  considerable  quantity  of  gas  and  pass  urine  of  light 
color  and  low  specific  gravity.  Death  may  take  place  during  the  paroxysm 
or  unconsciousness  may  supervene,  from  which  the  patient  recovers. 

The  diagnosis  in  marked  instances  is  not  difficult  but  the  milder  forms, 
which  are  frequently  observed,  are  likely  to  be  difficult  of  separation  from  the 
so-called  re-jiex  or  pseudo-angina  pectoris.  The  latter  may  occur  at  any  age 
and  is  more  common  in  women  of  hysterical  type  and  deteriorated  condition, 
it  is  not  associated  with  arteriosclerosis,  the  pain  lasts  longer  and  the  patient 
is  excited  and  agitated  during  the  paroxysm,  while  the  subject  of  a  true  anginal 
attack  is  quiet.  The  attacks  of  pseudo-angina  are  often  periodical  and 
may  occur  at  night  while  the  contrary  is  the  case  with  true  angina.  In  the 
false  angina  due  to  excessive  use  of  tobacco,  tea  or  coffee,  there  is  a  history 


ANGINA    PECTORIS.  605 

of  the  habit,  the  heart  is  rapid  and  irregular  and  arteriosclerosis  is  not  a 
prominent  feature. 

The  prognosis  is  grave;  the  patient  may  die  in  his  first  or  in  a  subsequent 
paroxysm;  sudden  death  may  take  place  in  the  interval  or  there  may  be  recur- 
rent attacks  for  years  until  finally  the  fatal  one  takes  place. 

Treatment  consists  in  the  employment  as  a  routine  of  means  calculated  to 
combat  the  sclerotic  condition  of  the  arteries  (see  p.  608).  In  syphilitic 
aortitis  antiluetic  medication  is  indicated.  The  patient  should  lead  a  quiet 
life  and  should  avoid  all  excesses  that  are  likely  to  bring  on  a  paroxysm; 
he  should  take  care  not  to  become  over-fatigued  mentally  or  physically  and 
should  never  over -load  his  stomach.  The  diet  should  be  of  simple  and  easily 
digested  foods;  intestinal  fermentation  and  constipation  should  receive  appro- 
priate treatment.  Alcohol  in  excess  should  be  forbidden;  tea,  coffee,  and 
tobacco  should  be  interdicted;  even  a  room  in  which  others  are  smoking  should 
be  avoided  by  the  patient. 

The  attack  may  be  relieved  by  the  inhalation  of  amyl  nitrite.  This  drug 
is  dispensed  in  glass  capsules  which  contain  3  to  5  minims  (0.20  to  0.33)  and 
of  which  the  patient  may  easily  keep  several  in  his  pocket  for  use  in  emergency; 
at  the  beginning  of  the  paroxysm  one  is  broken  upon  the  handkerchief  and  its 
fumes  are  inhaled.  If  amyl  nitrite  alone  fails  to  benefit,  the  following  capsule 
may  be  prescribed  and  may  afford  relief  within  a  few  moments:  I^  glycerylis 
nitratis,  gr.  y|o-  (0.0006);  menthohs,  gr.  -V  (0.0012);  amylis  nitritis,  n^  J  (0.016); 
oleoresinas  capsici,  gr.  j^-q  (0.0006).  Misce  et  fiat  capsula  numero  i.  Signa, 
take  one  capsule  at  the  beginning  of  an  attack.  In  obstinate  instances  a 
hypodermatic  injection  of  morphine  sulphate,  gr.  J  (0.065)  with  j^q  of  a 
grain  (0.0006)  of  atropine  sulphate  may  be  given  and  until  its  effect  is  evident 
inhalations  of  chloroform  or  aether  should  be  administered.  The  application 
of  heat  in  the  form  of  compresses,  a  hot  water  bag  or  mild  mustard  pouhices, 
to  the  chest  may  ease  the  patient  and  cold  compresses  may  act  as  well.  When 
failure  of  the  heart's  action  is  present  alcohol  and  ammonium,  especially  the 
aromatic  spirit,  are  indicated. 

During  the  intervals  of  the  attacks  the  iodides  should  be  administered  if 
there  are  signs  of  arteriosclerosis,  and  glyceryl  nitrate,  if  there  is  any  tendency 
to  arterial  contraction  should  be  given  in  doses  of  y|-o  to  j^  of  a  grain  (0.0006 
to  0.0012)  every  three  or  four  hours  until  its  physiological  effect  is  evidenced 
by  flushing  of  the  face  or  a  feeling  of  fulness  in  the  head.  A  combination  of 
arsenic  and  potassium  or  so'dium  iodide  often  acts  better  than  the  iodide  alone. 
The  following  formula  is  suggested:  I^  sodii  arsenatis,  gr.  v  (0.33);  sodii  vel 
potassii  iodidi,  §ss  (15.0);  aquae  destillatas,  q.s.  ad  §iv  (j.20.0).  Misce  et  signa, 
one  teaspoonful  (4.0)  thrice  daily  after  meals.  Usually  the  administration  of 
the  iodides  should  be  omitted  for  about  ten  days  of  every  month;  during  the 
interval  glyceryl  nitrate  may  be  given.     This  intermittent  employment  of  the 


6o6  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

iodides  may  be  continued  for  years.  If  the  iodides  are  not  well  borne  the 
tincture  of  iodine  in  doses  of  lo  drops  (0.66)  twice  a  day  may  be  substituted. 
Warm  carbonic  acid  gas  baths  (see  p.  551)  are  often  serviceable.  Digitalis 
should  not  be  given. 

In  pseudo-angina  of  the  neurotic  type  we  should  employ  the  means  suitable 
to  hysteria  of  other  forms,  especially  galvanic  electricity  and  hydrotherapeutic 
measures.  Musk,  asafoetida,  valerian  and  monobromated  camphor  in  ordi- 
nary doses  may  be  employed,  and  the  tincture  of  Crataegus  oxycantha  in  10  to 
20  drop  (0.66  to  1.33)  doses  is  suggested.  Sodium  iodide  may  be  adminis- 
tered in  2  or  3  grain  (0.13  to  0.20)  doses  three  times  a  day  as  a  preventive 
measure. 

DISEASES  OF  THE  BLOOD-VESSELS. 

ARTERIOSCLEROSIS. 

Synonyms.  Chronic  Endarteritis;  Arterio-capillary  Fibrosis;  Atheroma  of 
the  Blood-vessels. 

Definition.  A  cloronic  inflammatory  process  affecting  first  the  intima  of 
the  arteries,  but  later  spreading  to  the  media  and  adventitia,  and  character- 
ized by  an  increasing  thickening  and  loss  of  flexibility  of  the  arterial  wall. 

.Etiology.  Thickening  of  the  arteries  is  one  of  the  changes  which  occur 
gradually  as  the  years  of  life  advance,  but  the  tendency  to  its  occurrence  is 
very  variable,  depending  upon  a  number  of  factors.  Heredity  has  a  certain 
influence  and  the  affection  is  more  common  in  men  than  in  women.  Other 
influences  which  bear  a  direct  relation  to  the  incidence  of  arteriosclerosis 
are  over-eating  and  drinking,  a  life  at  high  nervous  pressure,  excessive  pro- 
longed muscular  exertion,  chronic  diseases  such  as  gout  or  plumbism,  the  late 
changes  due  to  syphilitic  poison  and  the  degenerations  occurring  in  the  acute 
infectious  diseases,  especially  enteric  fever.  The  abuse  of  alcohol  in  the 
light  of  recent  research  is  beginning  to  be  considered  a  less  important  aetiolog- 
ical  factor  than  formerly.  Clinicians  differ  as  to  the  influence  of  renal 
disease  upon  the  production  of  arterial  degeneration  but  it  is  probable  that 
there  are  two  types,  one  in  which  the  arterial  change  is  primary  and  the  other 
in  which  this  is  secondary  to  the  renal  affection.  Whether  chronic  hyper- 
tension in  the  vascular  system  influences  the  production  of  arterio-capillary 
fibrosis  or  whether  the  former  is  the  result  of  the  latter  is  also  a  source  of 
difference  of  opinion  but  it  seems  to  be  an  assured  fact  that  increased  tension 
may  exist  primarily  in  certain  subjects  and  that  these  later  exhibit  arterial 
degeneration.     Arteriosclerosis  is  often  associated  with  thyroid  enlargement. 

Pathology.  The  arterial  wall  having  been  weakened  through  some  degen- 
erative influence,  a  hyperplasia  of  the  intima  takes  place  in  order  to  restore 


ARTERIOSCLEROSIS.  607 

the  normal  calibre  of  the  vessel,  or  to  compensate  for  the  dilatation  of  the 
artery  which  has  followed  an  increase  in  blood-pressure,  there  is  an  increase 
in  the  intimal  connective  tissue. 

The  morbid  changes  may  involve  the  aorta  alone  or  in  connection  with 
other  groups  of  arteries,  or  the  whole  arterial  system  may  be  affected.  The 
cerebral  and  coronary  arteries  are  common  seats  of  arteriosclerosis  while 
those  of  the  viscera  are  seldom  diseased.  When  the  sclerosed  vessel  is  so 
situated  as  to  permit  of  examination  during  life,  as  in  the  case  of  the  temporals 
and  radials,  it  may  be  visibly  enlarged,  tortuous  and  even  beaded  in  appear- 
ance. To  palpation  it  is  hard  and  it  may  be  rolled  under  the  finger.  The 
small  internal  vessels  may  be  found  to  exhibit  whitish  patches  of  atheroma. 
The  lining  of  the  a£fe(!ted  arteries  is  rough  and  their  calibre  is  lessened.  Micro- 
scopically the  intima  in  the  earlier  stages  presents  certain  thickened  yellowish 
areas  of  cell-infiltration,  later  these  patches  soften  and  disintegrate,  forming 
the  atheromatous  abscesses,  the  contents  of  which  is  a  granular  debris  consist- 
ing of  cells  which  have  undergone  fatty  degeneration  and  crystals  of  choles- 
terin.  The  later  stage  of  the  abscess  is  an  ulceration  which  may  extend 
through  the  intima  and  finally  lead  to  aneurj'sm.  Still  later  the  media  and 
adventitia  are  involved  and  become  infiltrated  with  connective  tissue  which 
may  degenerate  and  lead  to  atheromatous  cysts,  which,  like  the  abscesses  of 
the  intima,  may  ultimately  become  ulcers.  Deposits  of  calcium  salts  may 
take  place  in  the  new  connective  tissue  growth. 

The  media  or  muscular  coat  may  undergo  calcareous  degeneration  without 
associated  other  change,  this  form  of  arteritis  being  a  common  senile  lesion. 

The  results  of  arterial  degeneration  are  a  rigidity  and  narrowing  of  the 
lumen  of  the  affected  vessel  which  causes  a  loss  of  elasticity,  a  slowing  of  the 
circulating  blood  current  and  heightened  blood-pressure.  As  a  consequence 
the  left  ventricle  of  the  heart  becomes  hypertrophied.  Ultimately  the  inter- 
ference with  the  circulation  brings  about  a  defective  state  of  nutrition  of  the 
heart  muscle,  the  parenchyma  of  the  kidneys  and  other  viscera,  which  is 
followed  by  interstitial  changes  in  these  organs.  The  vascular  changes  also 
predispose  to  the  occurrence  of  thrombosis,  embolism  and  rupture,  which, 
taking  place  in  the  cerebral  circulation,  result  in  apoplectic  attacks.  Rupture 
is  often  preceded  by  aneurysmal  dilatation  of  the  affected  artery  due  to  weak- 
ening of  its  wall  by  degeneration. 

Symptoms.  The  arteries  which  lie  near  the  surface  may  be  visibly  tortuous 
and  enlarged  and  the  examining  finger  easily  detects  their  thickened  walls 
and  the  increase  of  vascular  tension.  The  normal  artery  may  be  so  com- 
pressed by  the  finger  that  its  outline  can  scarcely  if  at  all  be  made  out,  and 
even  if  increased  tension  is  present,  the  pulsation  upon  the  distal  side  of  the 
compression  is  obliterated.  The  atheromatous  vessel  can  be  rolled  beneath 
the  finger  and  even  firm  pressure  is  not  sufficient  to  wholly  obliterate  the 


6o8  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

pulsation  beyond  the  compression.  The  physical  signs  of  left  ventricular 
hypertrophy  are  present  and  the  second  aortic  sound  is  clear,  sharp  and  ac- 
centuated— a  very  important  sign.  It  must  not  be  forgotten  that,  while  the 
arteries  which  are  palpable  may  be  in  normal  condition,  those  elsewhere  may 
be  the  seat  of  advanced  disease.  The  pulse  is  hard  and  tense  and  may  be  re- 
tarded, i.e.,  the  apical  impulse  may  occur  an  appreciable  time  before  the  wave 
reaches  the  v^ist.  If  hypertension  is  present  the  pulse  rate  is  not  lessened 
by  changing  from  standing  to  a  recumbent  posture  (Huchard's  sign). 

"When  the  coronary  arteries  are  involved  the  heart  may  become  the  seat 
of  fibroid  myocarditis  or  cardiac  aneurysm,  sudden  death  from  thrombosis 
may  occur  or  the  patient  may  sufler  from  attacks  of  angina  pectoris;  even 
cardiac  rupture  may  take  place.  If  dilatation  succeeds'  upon  the  ventricular 
hypertrophy  the  symptoms  of  this  condition  are  present. 

Arteriosclerosis  of  the  cerebral  vessels  causes  dizziness  and  insomnia  and 
predisposes  to  the  various  degenerative  conditions  which  may  result  from 
insufficient  blood  supply  of  the  brain.  Apoplectic  attacks  are  common  and 
the  occurrence  of  temporary  paralyses  or  of  aphasia,  which  may  last  but  a 
few  hours  and  then  entirely  disappear,  is  not  infrequent.  The  pathogenesis 
of  these  latter  is  not  satisfactorily  explainable.  The  Adams-Stokes  syndrome 
has  been  observed. 

The  atheroma  of  the  arteries  within  the  kidneys  results  in  an  arterial  neph- 
ritis (see  p.  696). 

Intermittent  claudication  (Charcot's  symptom)  a  condition  characterized  by 
lameness,  muscular  pain  and  weakness  of  the  legs  with  numbness,  tingling  and 
various  other  disorders  of  sensation  occurring  after  slight  exertion,  is  a  symptom 
which  has  recently  caused  considerable  discussion.  It  is  supposed  to  be  due  to 
the  diminished  blood  supply  dependent  upon  the  arterial  disease.  Examination 
reveals  congestion  of  the  lower  extremities,  thickening  of  their  arteries  and 
perhaps  absence  of  pulsation  in  the  dorsalis  pedis  artery. 

The  occurrence  of  embolism  or  thrombosis  in  the  terminal  arteries  of  the 
extremities  leads  to  gangrene. 

The  prognosis  is  variable.  So  long  as  the  compensatory  hypertrophy  of 
the  heart  is  able  to  maintain  a  good  circulation  the  subject  of  even  advanced 
arterial  disease  may  live  in  comfort  for  years  but  there  is  always  the  possibility 
of  the  incidence  of  cerebral  apoplexy,  the  rapid  development  of  renal  disease 
or  of  loss  of  cardiac  compensation. 

Treatment.  In  the  early  stages  before  the  onset  of  symptoms  the  patient's 
condition  should  be  explained  to  him  and  he  should  be  told  that  he  may, 
to  a  considerable  extent,  delay  and  perhaps  escape  the  discomforts  and 
dangers  to  come  by  regulating  his  mode  of  life.  Both  mental  and  physical 
fatigue  should  be  avoided  and  the  use  of  alcohol  should  be  forbidden.  If 
there  is  objection  to  entirely  giving  up  this  and  tobacco,  they  must  be  used 


ARTERIOSCLEROSIS.  609 

only  with  the  greatest  moderation.  Moderate  exercise  may  be  taken  and 
daily  walks  should  be  advised.  Cool  bathing,  followed  by  massage  and 
friction,  is  beneficial.  Over-eating  must  be  restricted  and  the  character  of 
the  food  should  be  regulated.  Meat  should  be  reduced  to  a  minimum  since 
it  contains  a  large  amount  of  tissue  forming  elements  and  extractives.  Foods 
rich  in  calcium  salts,  such  as  milk,  cheese,  rice,  etc.,  theoretically  are  contra- 
indicated,  but  practically  it  seems  to  be  more  important  to  restrict  the  quantity 
of  food  than  its  quality.  A  mixed  diet,  small  in  amount  and  consisting  of 
milk,  best  taken  diluted  with  mineral  water,  eggs,  vegetables  and  a  moderate 
quantity  of  fresh  well-done  meat  is  best.  Little  fluid  should  be  taken  with 
meals.  Exercise  in  the  fresh  air  is  important  and  frequent  vacations  are  to 
be  advised.  The  preferable  climate  is  one  of  mild  and  equable  temperature 
and  of  low  altitude;  the  subjects  of  arteriosclerosis  do  not  usually  do  well 
above  a  level  of  600  to  800  yards. 

The  digestion  should  be  kept  in  as  normal  a  state  as  possible  and  intestinal 
fermentation  and  constipation  if  present  should  be  corrected.  The  routine 
unloading  of  the  bowels  every  few  weeks  by  means  of  a  course  of  fractional 
doses  of  calomel  followed  by  a  saline  is  often  a  source  of  considerable  relief 
to  the  patient  after  the  symptoms  of  venous  congestion  have  become  manifest. 

Since  the  presence  of  arteriosclerosis  is  in  great  measure  the  result  of  the 
continued  maintenance  of  an  increased  blood  pressure,  in  the  prophylaxis 
of  this  condition  all  means  to  prevent  and  to  lessen  hypertension  should  be 
employed. 

It  is  possible  that  we  may  delay  the  further  formation  of  connective  tissue 
within  the  walls  of  the  arteries  and  less  so  that  the  absorption  of  that  already 
present  may  be  promoted  by  means  of  the  iodides.  Sodium  iodide  is 
preferred  by  some  clinicians  because  it  is  better  tolerated  than  potassium 
iodide;  the  former  is,  however,  less  active  than  the  latter  and  consequently 
should  be  given  in  larger  dosage  to  secure  an  equivalent  effect.  Either  may 
be  taken  in  doses  of  10  to  20  grains  (0.66  to  1.33)  three  times  a  day  but  in 
order  to  establish- a  tolerance  the  beginning  dose  should  be  small,  3  to  5 
grains  (0.2  to  0.33)  and  gradually  increased.  The  iodide  treatment  may  be 
continued  for  a  number  of  years  with  intervals  of  omission  such  as  one  week 
every  month  or  one  month  in  every  six. 

In  conditions  of  hypertension  the  nitrites  should  be  freely  used,  preferably 
erythrol  tetranitrate  in  doses  of  ^o  to  ^  a  grain  (0.006  to  0.032);  this  drug  is 
usually  well  borne  and  may  be  given  for  considerable  periods  without  increas- 
ing the  dose.  Glyceryl  nitrate  in  doses  of  y^o"  to  5V  of  a  grain  (0.0006  to 
0.0012)  is  also  reliable.  Attacks  of  marked  dyspnoea  associated  with  high 
arterial  tension  may  be  relieved  by  venesection. 

Recently  Trunecek's  artificial  serum  has  been  much  employed  in  arterial 
degeneration.     This  substance  contains  the  normal  blood  salts  and  is  sup- 
39 


6lO  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

posed  to  better  the  nutrition  of  the  artery  wall  by  rendering  the  blood  more 
nearly  normal  in  constituency.  It  may  be  given  in  tablets  each  of  which  con- 
tains sodium  chloride,  6^  grains  (0.4),  sodium  sulphate,  f  grain  (0.04),  mag- 
nesium phosphate  and  sodium  carbonate,  of  each  J  grain  (0.015),  sodium 
phosphate  and  calcium  glycerophosphate,  of  each  ^  grain  (0.0125). '  Of  these 
two  should  be  given  three  times  a  day. 

The  feeble  heart  and  the  palpitation  which  occur  in  the  later  stages  should 
be  treated  according  to  the  methods  described  in  previous  sections.  When 
digitalis  is  prescribed  arterial  dilators  should  always  accompany  it.  Stroph- 
anthus  is  often  the  preferable  heart  stimulant  because  of  its  less  vaso-con- 
strictor  action. 

Coronary  arteritis  should  be  managed  in  accordance  with  the  principles 
suggested  in  the  section  upon  angina  pectoris,  and  the  treatment  of  the  renal 
type  of  arterial  degeneration  is  discussed  in  the  chapter  upon  arterial  (inter- 
stitial) nephritis. 

In  all  instances  in  which  there  is  a  syphilitic  element  in  the  history  a  course 
of  mercurial  and  iodide  treatment  is  indicated. 

ANEURYSM. 

Definition.     A  dilatation,  more  or  less  circumscribed,  of  a  blood-vessel. 
Aneurysms  occur  in  various  forms. 

1.  True  aneurysm,  one  in  which  the  wall  of  the  dilatation,  at  iirst,  at  least,  is 
composed  of  all  three  coats  of  the  artery.  Of  true  aneurysms  there  are  several 
subdivisions:  a.  Fusiform  aneurysm  in  which  the  dilatation  is  spindle  shaped 
and  involves  the  entire  circumference  of  the  vessel  wall. 

h.  Sacculated  aneurysm  in  which  the  dilatation  involves  but  a  part  of  the 
circumference  and  communicates  with  the  lumen  of  the  artery,  from  which 
it  is  an  offshoot,  by  an  opening  of  varying  size. 

c.  Cirsoid  aneurysm  is  a  tortuous  and  irregular  dilatation  involving  a 
medium  sized  artery  and  its  branches.  This  condition  is  analogous  to  the 
varicosities  which  occiir  in  veins. 

2.  False  aneurysm  may  occur  as  a  result  of  a  traumatism  which  weakens 
the  resistance  of  the  intima  to  the  blood  pressure  and  this  coat  is  consequently 
pushed  through  the  elastic  muscular  coat  and  a  dilatation  results  which  involves 
only  the  intima  and  the  adventitia.  Injuries  to  blood-vessels  may  also  cause 
the  so-called  arterio-venous  aneurysm  which  is  the  term  applied  to  a  commu- 
nication between  an  artery  and  a  vein;  the  latter  is  dilated  and  tortuous  and 
the  condition  is  also  denominated  aiteurysmal  varix.  If  a  saccular  dilatation 
is  present  at  the  junction  of  the  two  vessels  the  lesion  is  called  a  varicose 
aneurysm.  The  dissecting  aneurysm  may  likewise  result  from  trauma.  It  is 
usually  observed  in  the  aorta;  the  blood  as  a  consequence  of  the  injury  to  the 


ANEURYSM    OF    THE    THORACIC    AORTA.  6ll 

inner  coats  is  able  to  force  its  way  between  these  and  the  adventitia  and  may 
separate  these  layers  for  a  considerable  distance  and  finally  form  a  complete 
double  tube. 

Etiology.  Aneurysms  are  more  frequent  in  males  than  in  females  and 
are  most  usual  after  middle  life  when  the  degenerative  processes  have  begun. 
The  causes  of  aneurysm,  other  than  trauma,  are  practically  identical  with 
those  of  arteriosclerosis,  syphilis  being  perhaps  the  most  common  single  aetio- 
logical  factor.  The  aortitis  resulting  from  luetic  disease  leads  to  weakening 
of  the  vessel  wall  and  consequent  dilatation  in  numerous  instances.  The 
lodgment  of  emboli  in  smaller  vessels  is  often  followed  by  aneurysmal  dilata- 
tion behind  the  stoppage  and  if  the  embolus  is  septic,  infection  follows.  Com- 
pression is  said  to  exert  a  certain  influence  in  the  causation  of  aneurysm, 
the  popliteal  variety  being  said  to  occur  as  a  result  of  frequent  crossing  of  one 
knee  over  the  other.  The  lesion  is  also  met  in  multiple  form  in  malignant 
endocarditis,  where,  in  addition  to  the  valvular  ulcerations,  aortic  aneurysms 
may  be  formed. 

Aneurysm  of  the  Thoracic  Aorta. 

Aortic  aneurysm  is  usually  met  in  subjects  of  beginning  arteriosclerosis 
before  the  compensating  growth  of  connective  tissue  in  the  media  has  taken 
place,  and  as  an  exciting  cause  an  unusual  muscular  exertion,  which  weakens 
or  ruptures  the  intima  leading  to  subsequent  dilatation,  may  be  considered. 
The  aneurysm  may  be  either  fusiform  or  sacculated,  the  latter  being  the  more 
common.  The  most  frequent  situation  is  at  the  beginning  of  the  aorta  just 
behind  the  pulmonary  artery  and  as  a  result  of  compression  of  this  vessel 
there  may  be  hypertrophy  of  the  right  ventricle.  Perforation  into  the  pul- 
monary artery  or  into  the  pericardium  may  take  place.  An  aneurysm  of  the 
ascending  aorta  just  behind  the  junction  of  the  gladiolus  and  manubrium 
may  project  forward  and  finally  rupture  externally.  Aneurysm  of  the  con- 
vexity of  the  arch  pointing  toward  the  right  becomes  adherent  to  the  pleura 
and  ultimately  may  erode  the  lung  and  result  fatally  with  haemoptysis.  Dila- 
tation at  the  summit  of  the  arch  presses  upon  and  may  erode  the  trachea. 
Aneurysm  of  the  descending  aorta  usually  protrudes  posteriorly  and  laterally. 

Symptoms.  These  are  chiefly  due  to  the  pressure  of  the  tumor  upon  the 
neighboring  structures.  Aneurysm  of  the  ascending  portion  of  the  arch 
causes  pain  through  pressure  upon  the  sternum  and,  in  late  stages,  an  external 
tumor.  By  pressure  upon  the  superior  cava  or  the  subclavian  vein  it  causes 
congestion  and  oedema  of  the  head  and  arm.  If  of  large  size  the  tumor  may 
displace  the  heart  downward  and  to  the  left,  or  extending  to  the  right,  cause 
paralysis  of  the  right  vocal  cord  due  to  pressure  upon  the  right  recurrent 
laryngeal  nerve.  Aneurysm  in  this  situation,  as  stated  above,  may  rupture 
into  the  pericardium,  the  pleura  or,  rarely,  externally. 


6l2  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

A  peculiar  dilatation  of  the  first  part  of  the  aorta,  first  described  by  Hodgson 
and  still  known  as  Hodgson's  disease,  is  not  uncommon.  The  vessel  forms 
a  pouch  beginning  just  above  the  semilunar  valves  and  more  rarely  involving 
only  one  side  of  the  aorta.  The  resulting  symptoms  are  dyspnoea  due  to 
tracheal  pressure,  palpitation,  cough  with  mucoid  expectoration,  insomnia 
and  attacks  of  fainting.  The  physical  signs  are  an  increased  dulness  over 
the  ascending  aorta  demonstrating  an  increase  in  the  width  of  the  aorta,  pro- 
longation of  the  systole,  and  cardiac  dilatation  with  the  murmilr  of  a  relative 
aortic  insufficiency. 

Aneurysms  of  the  transverse  portion  of  the  aorta  cause  pain  due  to  pressure 
upon  the  vertebral  column  if  they  protrude  posteriorly  or  to  erosion  of  the 
sternum  if  they  grow  forward.  The  external  tumor  is  usually  in  the  mid- 
line of  the  chest  or  to  the  right  of  the  sternum.  Pressure  upon  the  trachea 
causes  cough  and  dyspnoea,  upon  the  oesophagus  dysphagia,  upon  the  left 
recurrent  laryngeal  nerve  paralysis  of  the  corresponding  vocal  cord  with 
aphonia  or  hoarseness,  upon  the  sympathetic  nerve,  fkst,  pupillary  dilatation, 
later,  contraction.  Large  aneurysms  of  the  arch  may  fill  the  entire  upper 
mediastinum  from  pleura  to  pleura  and  from  sternum  to  vertebral  column. 

Aneurysm  involving  the  descending  arch  causes  a  tumor  extending  pos- 
teriorly and  to  the  left  with  consequent  vertebral  pain  and  even  a  protruding 
tumor  adjacent  to  the  left  scapula.  Pressure  on  the  oesophagus  is  frequent 
and  rupture  into  the  pleura  or  into  the  lung  itself  may  occur. 

Aneurysm  of  the  thoracic  aorta  below  the  arch  may  be  present  without 
giving  rise  to  suggestive  symptoms.  In  other  instances  there  is  pain  due  to 
vertebral  pressure  and  interference  with  swallowing.  The  tumor  may  mani- 
fest itself  externally,  usually  to  the  left  of  the  vertebral  column. 

The  pressure  pain  of  aneurysm  is  not  always  present  but  may  be  a  very 
distressing  symptom;  it  may  occur  in  paroxsysms  and  is  sharp  and  cutting 
in  character  especially  when  the  tumor  is  eroding  a  bone.  In  involvement 
of  the  first  part  of  the  aorta,  anginoid  attacks  are  frequent.  Pressure  upon 
the  spinal  nerve  roots  may  cause  pain  radiating  down  the  arm. 

Cardiac  and  Circulatory  Symptoms.  These  consist  of  a  relative  aortic  insuf- 
ficiency, occurring  in  dilatation  of  the  ascending  limb  of  the  arch,  and  muscular 
hypertrophy  in  a  certain  number  of  instances.  The  pressure  of  the  aneu- 
rysmal tumor  upon  the  veins  draining  the  arm  and  head  causes  flushing  and 
cedema  of  these  parts.  Pressure  may  be  exerted  upon  the  pulmonary  artery 
and  at  times  an  insufiiciency  of  the  valve  may  result.  Rupture  of  the  aneurysm 
into  this  vessel  may  occur. 

Respiratory  Symptoms.  Dyspnoea  due  to  pressure  on  the  trachea  or  a 
bronchus  is  common  in  dilatations  of  the  transverse  portion  of  the  arch.  Cough 
may  also  result  from  this  pressure  or  from  accompanying  bronchitis;  the  spu- 
tum may  be  mucoid  or  thick  and  purulent.     The  typical  brassy  cough  of 


ANEURYSM    OF    THE    THORACIC    AORTA.  613 

aneurysm  which  presses  upon  the  recurrent  laryngeal  nerves  may  be  present 
and,  associated  with  it,  hoarseness  or  aphonia  are  not  uncommon.  Haemoptysis 
occurs  as  a  result  of  rupture  of  the  aneurysm  into  the  trachea  or  bronchi, 
of  erosion  of  pulmonary  tissue  or  from  the  granulation  tissue  developed  in 
the  trachea  at  the  site  of  the  pressure.  Haemorrhage  from  rupture  usually 
causes  death;  other  forms  of  haemorrhage  may  gradually  exsanguinate  the 
patient  and  prove  very  exhausting  but  seldom  of  themselves  result  fatally. 

Other  pressure  symptoms  are  dysphagia,  occurring  when  the  lumen  of 
the  oesophagus  is  encroached  upon  by  the  tumor,  and  pupillary  and  vaso-motor 
manifestations  which  are  caused  by  interference  with  the  normal  functions 
of  the  sympathetic  nerve.  These  are  most  common  in  aneursym  of  the  ascend- 
ing arch  and  consist,  if  irritation  only  is  the  result  of  the  pressure,  of  pupillary 
dilatation  and  paleness  of  the  face  upon  the  same  side.  More  marked  pres- 
sure causes  paralysis  of  the  nerve  and  consequent  contraction  of  the  pupil 
and  congestion  of  half  the  face,  sometimes  with  hyperidrosis. 

Physical  Signs.  Inspection  may  reveal  a  pulsation  above  the  base  of  the 
heart.  This  may  be  invisible  except  in  strong  light  and  is  more  likely  to 
appear  upon  the  left  than  on  the  right  side  of  the  sternum.  The  impulse 
may  also  be  visible  in  the  supra-sternal  notch.  When  the  aneiurysm  has 
reached  sufficient  size  a  bulging  of  the  chest  or  a  distinct  tumor  becomes 
apparent,  to  the  right  of  the  sternum  if  the  ascending  portion  of  the  arch  is 
affected,  behind  and  above  the  sternum  if  the  lesion  is  of  the  transverse  por- 
tion, to  the  left  if  the  dilatation  involves  the  descending  portion.  Finally  the 
tumor  eats  its  way  through  the  intervening  structures  until  it  is  covered  merely 
by  the  skin  which  becomes  smooth,  tense  and  glossy.  The  pulsation  of  the 
tumor  is  ventriculo-systolic  in  time  and  expansile  in  character.  The  apex 
beat  of  the  heart  may  be  displaced  downward  by  the  pressure  of  the  growth 
or  to  the  left  as  a  result  of  ventricular  h}rpertrophy.  Pressure  upon  the  venous 
circulation  of  the  neck  causes  congestion  and  oedema  of  one  or  both  sides 
depending  upon  the  site  of  the  interference  with  circulation.  Pressure  upon 
the  innominate  or  subclavian  veins  produces  interference  with  the  circulation 
of  the  upper  thorax  and  arms.  Pupillary  abnormality  may  be  noted  as  a 
result  of  pressure  upon  the  sympathetic  nerve.  Laryngoscopic  examination 
shows  paralysis  of  one  or  other  of  the  vocal  cords  according  to  the  situation 
of  the  lesion.  Visible  depression  of  the  larynx  with  each  cardiac  contraction 
may  be  noticed  when  the  trachea  is  put  on  the  stretch  by  holding  the  head  back. 

Palpation  confirms  the  evidence  obtained  by  inspection.  The  pulsation 
is  felt  to  be  distinctly  expansile  in  character.  A  ventriculo-systolic  thrill 
and  the  diastolic  shock,  an  important  sign,  due  to  the  recoil  blow  of  the  tumor 
upon  the  closed  aortic  valve,  may  be  present.  The  examiner  may  elicit 
tenderness  upon  pressure  over  the  aneurysm;  if  the  dilatation  is  large  and 
superficial  it  should  be  palpated  and  percussed  with  great  care.     The  tracheal 


6l4  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

tug  is  elicited  by  inserting  tlae  thumb  and  forefinger  beneath  the  cricoid  car- 
tilage and  lifting  this  structure.  With  each  systole  a  downward  pull  may  be 
felt;  a  sidewise  movement  may  also  be  detected  (Cardarelli's  sign). 

Percussion.  The  note  over  all  but  small  and  deeply  situated  aneurysms  is 
dull  or  flat  and  this  note  may  be  elicited  over  the  parts  of  the  lung 
nearest  to  the  tumor  as  a  result  of  compression  of  this  organ.  Aneurysm  of 
the  ascending  arch  causes  a  change  in  the  resonance  over  the  upper  ribs  and 
intercostal  spaces  upon  the  right  side  near  the  sternum.  Dulness  over  this 
structure  and  to  its  left  is  caused  by  dilatations  of  the  transverse  portion;  the 
change  in  note  over  aneiu^ysms  of  the  descending  arch  is  in  front,  obscured  by 
the  normal  cardiac  dulness  and  the  deep  situation  of  the  vessel.  Dulness  is, 
however,  in  instances  of  anevirysm  of  this  situation,  perceptible  posteriorly 
in  the  region  of  the  left  scapula  and  between  this  bone  and  the  vertebral 
column. 

Auscultation  is  often  unproductive  of  any  evidence;  in  other  instances  it 
may  reveal  most  characteristic  signs.  A  variety  of  murmurs  may  be  produced 
in  aneurysms.  A  ventricido-systolic  murmur  or  even  a  double  bruit  may 
be  present,  the  ventriculo-diastolic  sound  being  the  result  of  relative  insuffi- 
ciency of  the  aortic  valve.  In  quality  the  aneurysmal  murmur  may  be 
rough,  soft  or  musical  and  it  is  probably  due  to  the  passage  of  the  blood 
current  over  the  roughenings  in  the  lining  of  the  dilatation.  The  ventriculo- 
diastolic  bruit  which  may  be  heard  at  times  in  aneurysms  distant  from  the 
aortic  valve  may  be  caused  by  the  propulsion  of  the  blood  tlirough  the  sac  or 
to  its  recoil  as  it  propels  the  blood  stream  onward.  In  the  larger  aneu- 
rysms of  the  arch  an  important  sign  is  a  sharp,  ringing  second  aortic  sound. 
This  may  be  absent  and  is  not  marked  if  the  aortic  valve  is  unsound.  A 
systolic  murmur  may  be  audible  over  the  trachea  or  even  at  the  patient's 
open  mouth  (Drummond's  sign),  and  in  latent  aneurysm  there  may  be  a 
systolic  sound  in  the  brachial  artery  (Glasgow's  sign). 

Changes  in  the  pulse  of  the  peripheral  arteries  are  not  infrequent.  The 
chief  of  these  is  a  retardation  of  the  impulse  in  arteries  beyond  the  dilatation. 
If  there  is  enfeeblement  or  delay  of  the  right  radial  pulse  the  dilatation  will 
be  on  the  right  side  and  affecting  the  innominate  artery.  If  the  change  in 
radial  pulse  is  upon  the  left  side  the  subclavian  artery  is  probably  involved. 
Large  thoracic  or  abdominal  aneurysm  may  cause  diminution  or  even  absence 
of  pulse  in  the  vessels  below  the  lesion. 

X-ray  examination  shows  that  aneurysm  of  the  ascending  aorta  usually 
casts  a  shadow  more  to  the  right  than  to  the  left  of  the  sternum,  above  the 
heart,  which  by  localization  would  be  found  to  be  nearer  the  anterior  than  the 
posterior  wall  of  the  chest. 

Dilatations  of  the  transverse  portion  cast  a  shadow  slightly  to  the  left  of 
the  sternum  extending  well  into  the  neck  and  nearer  the  anterior  thoracic 


ANEURYSM  OF  THE  ABDOMINAL  AORTA.  615 

wall;  if  the  lesion  is  of  the  descending  arch  the  shadow  is  cast  to  the  left  of 
the  sternum  and  nearer  the  posterior  wall  of  the  thorax. 

The  diagnosis.  Tumors  of  the  mediastinum  may  be  difi&cult  of  differen- 
tiation from  aneurysm  of  the  arch.  The  signs  elicited  by  percussion  may 
be  identical  and,  while  the  pain  is  often  similar  to  that  of  aneurysm,  there  is 
no  expansile  pulsation.  Cardiac  and  circulatory  symptoms  are  not  features 
of  neoplasm,  there  is  no  tracheal  tug  nor  are  laryngeal  symptoms  present. 
A  febrile  movement,  a  cachectic  condition  and  lymphoid  enlargements  are  to 
be  associated  with  mediastinal  new  growth;  pressiu-e  upon  the  oesophagus 
or  bronchi  is  common  to  both  tumor  and  aneurysm. 

Pulsating  empyema  in  the  region  of  the  heart  may  be  differentiated  from 
aneurysmal  dilatation  by  the  absence  of  the  diastolic  shock  and  tracheal 
tug;  the  pulsation  is  expansile,  however,  but  less  firm,  heaving  and  more  diffuse. 
The  history  also  should  aid  in  the  separation  of  the  two  conditions  and  an  as- 
sured diagnosis  may  be  made  by  the  use  of  the  exploring  needle. 

Aneurysm  may  be  mistaken  for  aortic  insufficiency  with  pulsation  of  the 
vessel  but  in  the  latter  condition  we  have  no  pressure  symptoms  nor  tracheal 
tug,  there  is  likely  to  be  a  rheumatic  history  and  the  patient  may  be  young 
or  only  middle  aged  and  not  a  subject  of  arteriosclerosis.  Cardiac  hyper- 
trophy is  more  frequent  in  the  cardiac  lesion  than  in  aneurysm. 

The  prognosis.  While  unsuspected  aneurysms  are  often  found  during 
autopsy  after  death  from  other  causes,  the  prognosis,  especially  when  the 
physical  signs  and  symptoms  are  well  marked,  is  always  grave  and  death 
results  from  rupture  of  the  sac,  erosion  of  a  blood-vessel,  etc.  Spontaneous 
cure  of  small  sacculated  aneurysms  may  occur,  the  cavity  becoming  gradually 
filled  with  fibrin  and  later  shrinking,  the  sac  becoming  ultimately  obliterated. 
Aneurysms  slowly  eroding  the  trachea  or  a  bronchus  may  cause  repeated 
small  haemorrhages  and  cause  death  from  increasing  weakness.  Under 
favorable  circumstances  and  proper  treatment  the  patient  may  be  made  com- 
fortable and  his  life  prolonged  for  a  considerable  period.  Cure  is  possible 
in  a  certain  number  of  patients. 

Aneurysm  of  the  Abdominal  Aorta. 

Aneurysm  of  this  vessel  is  not  of  common  occurrence,  a  visible  and  palpable 
pulsation  of  the  abdominal  aorta  is,  however,  frequently  observed  The 
usual  site  for  abdominal  aneurysm  is  near  the  origin  of  the  cceliac  axis.  Exten- 
sion of  the  tumor  backward  results  in  erosion  of  the  vertebral  column  and 
causes  a  constant  lumbar  pain  due  to  pressure  on  the  splanchnic  nerves  and 
solar  plexus,  or  a  neuralgic  pain,  due  to  pressure  upon  the  lumbar  nerves, 
which  may  be  referred  to  the  anterior  abdomen,  the  testicles,  down  the  limbs, 
and  in  fact  to  any  point  to  which  the  affected  nerves  are  distributed.     Growth 


6l6  DISEASES    OF    THE    HEART    AND    BLOOD- VESSELS. 

of  the  dilatation  forward  causes  pressure  upon  the  digestive  organs  and  results 
in  gastric  pain,  vomiting,  and  diarrhoea.  In  certain  instances  there  are  but 
few  and  ill-marked  symptoms,  as  in  a  patient  observed  by  the  writer  in  one  of 
the  workmen  attached  to  Bellevue  Hospital,  whose  attention  was  first  called 
to  his  disease  by  noticing  the  rise  and  fall  of  the  book  which  he  was  reading 
and  which  rested  upon  his  epigastrium,  the  man  meanwhile  lying  on  his 
back. 

The  physical  signs  are  analogous  to  those  of  thoracic  aneurysm.  Pulsa- 
tion may  be  visible  and  even  a  definite  tumor  may  be  made  out  in  certain 
subjects.  A  thrill  may  be  present  and  upon  palpation,  particularly  in  thin 
subjects,  the  aneurysm  may  be  grasped  and  its  expansile  pulsation  distinctly 
perceived;  this  last  is  essential  to  the  diagnosis  for  it  is  not  present  in  instances 
of  pulsating  aorta.  A  ventriculo-systolic  hniit,  more  rarely  a  double  mur- 
mur, may  be  audible  and  the  pulses  in  the  legs  are  usually  retarded  and  dimin- 
ished. Certain  neoplasms  in  the  epigastric  region  may  be  mistaken  for 
aneurysm  but   never  possess   true  expansile  pulsation. 

The  prognosis  is  unfavorable,  death  ensuing  from  rupture,  obliteration  of 
the  vessel  by  a  gradually  forming  clot  or  embolism  of  other  arteries,  more 
particularly  the  superior  mesenteric. 

Aneurysm  of  the  Branches  of  the  Abdominal  Aorta. 

Aneurysm  of  the  cceliac  axis  may  occur  by  itself  or  in  connection  with  dilata- 
tion of  the  aorta  itself.  The  symptoms  are  similar  to  those  of  aneurysm  of 
the  aorta  at  this  level;  the  origin  of  the  tumor  may  be  traumatic. 

Aneurysm  of  the  splenic  artery  is  usually  of  small  size  but  may  be  large 
enough  to  be  made  out  by  palpation.  In  such  instances  the  physical  signs 
are  those  of  a  tumor,  dull  on  percussion,  the  dulness  continuous  with  that  of 
the  spleen,  and  pulsation;  a  murmur  may  not  be  present;  the  symptoms  are 
those  of  digestive  disturbance  with  epigastric  pain  and  hcematemesis.  Rup- 
ture into  the  bowel  may  take  place  with  fatal  haemorrhage. 

Aneurysm  of  the  hepatic  artery  is  rare;  its  symptoms  are  not  characteristic. 
The  dilatation  is  usually  small  but  the  liver  itself  is  likely  to  be  the  seat  of 
marked   enlargement. 

Aneurysm  of  the  superior  mesenteric  artery  is  less  uncommon  but  is  difficult 
of  diagnosis  during  life. 

Aneurysms  of  the  renal  arteries  are  usually  small  and  often  traumatic  in 
origin.  Pulsation  and  murmurs  are  inconstant,  retro-peritonoeal  haemorrhage 
may  take  place  from  rupture. 

Aneurysm  of  the  pulmonary  artery  is  extremely  rare;  it  is  evidenced  by  a 
tumor  at  the  left  of  the  sternum  at  the  level  of  the  second  intercostal  space. 
Other  local  symptoms  of  aneurysm  are  present  but  the  hruit  is  often  absent. 


THE    TREATMENT    OF    ANEURYSM.  617 

There  is  no  recurrent  laryngeal  pressure  but  marked  dyspnoea  is  present  with 
cedema  and  lividity  of  the  face. 

The  Treatment  of  Aneurysm. 

Saccular  aneurysms  communicating  with  the  aorta  by  a  small  opening  may 
in  a  certain  number  of  instances  be  cured.  The  treatment  consists  in  the 
employment  of  measures  which  favor  the  formation  of  a  permanent  clot  within 
the  sac  which  shall  finally  become  solid  and  entirely  occlude  the  dilatation. 
To  further  this  occurrence  the  most  satisfactory  method  is  that  of  Tufnell, 
of  Dublin,  who  advises  complete  mental  and  bodily  rest  in  the  recumbent 
position.  This  reduces  the  blood  pressure  and  volume  of  blood  forced  through 
the  arterial  system  by  lessening  the  force  and  frequency  of  the  cardiac  contrac- 
tions. The  effect  of  this  treatment  is  furthered  by  restricting  the  diet.  That 
prescribed  by  Tufnell  is  as  follows:  Breakfast  and  supper  each  to  consist 
of  2  ounces  (60.0)  of  bread  and  butter  and  2  ounces  (60.0)  of  milk;  dinner, 
2  to  3  ounces  (60.0  to  90.0)  of  meat  and  3  to  4  ounces  (go.o  to  120.0)  of  milk 
or  claret.  This  regimen  is  very  rigid  and  necessitates  no  inconsiderable 
amount  of  courage  and  determination  on  the  part  of  the  patient.  It  is  prob- 
able that  the  solids  may  be  less  carefully  restricted  if  it  is  remembered  that  in 
order  to  maintain  a  continuously  low  blood  pressure,  but  little  fluid  should  be 
allowed.  The  treatment  should  be  continued  for  several  months  at  least 
and  longer  if  the  patient  will  endure  the  deprivation;  improvement  is  evidenced 
by  a  diminution  in  the  pulsation  and  size  of  the  tumor  and  an  amelioration 
of  the  pain.  It  is  important  in  this  and  other  methods  of  treatment  that  the 
bowels  should  be  kept  freely  open  in  order  that  the  blood  pressure  shall  not 
be  increased  by  the  incidence  of  constipation  or  of  straining  at  stool.  Balfour 
advises  the  employment  of  iodide  of  potassium  in  connection  with  the  Tufnell 
method.  Large  doses  are  unnecessary,  a  proper  amount  being  from  10  to  20 
grains  (0.66  to  1.33)  three  times  daily.  This  drug  affords  relief  from  the  pain 
in  a  certain  degree,  lowers  the  blood  pressure  and  is  considered  by  some  to 
thicken  the  blood  by  causing  an  increase  of  the  secretions;  it  may  be  given 
to  advantage  to  non-syphilitic  patients  as  well  as  to  those  who  give  a  history 
of  luetic  disease. 

Valsalva  has  recommended  venesection,  and  the  removal  of  small  amounts 
of  blood  may  be  practiced  with  the  result  of  relieving  the  pain  and  lessening 
the  blood  pressure. 

The  administration,  in  connection  with  other  treatment,  of  calcium  lactate, 
20  grains  (1.33)  three  times  a  day  is  suggested.  This  drug  markedly  increases 
the  coagulation  power  of  the  blood  and  should  aid  in  the  formation  of  the  clot 
in  the  aneurysmal  tumor.  It  should  not  be  forgotten,  however,  that  the  con- 
tinuation of  this  salt  for  more  than  three  or  four  days  at  a  time  results  in  di- 
minished coagulability. 


6l8  DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

The  treatment  by  means  of  hypodermatic  injections  of  gelatin  has  been 
employed  by  Lanceraux  who  has  reported  good  results  although  those  obtained 
in  this  country  have  been  less  favorable.  A  one  percent,  solution  of  gelatin 
in  normal  saline  (0.9  percent.)  solution  is  used.  Having  been  previously 
sterilized,  2  to  5  ounces  (60.0  to  150.0)  of  the  solution  at  a  temperature  of  about 
100°  F.  (37.8°  C),  are  injected  into  the  subcutaneous  tissue  of  the  thigh  or 
buttock;  the  procedure  is  repeated  from  fifteen  to  twenty  times  at  intervals 
of  from  six  days  to  two  weeks.  The  gelatin  is  supposed  to  increase  the 
coagulability  of  the  blood.  Tetanus  has  been  reported  as  following  this  treat- 
ment in  certain  instances  but  this  accident  is  doubtless  due  to  contamination 
of  the  solution.  The  internal  administration  of  gelatin  in  doses  of  4  drachms 
(15.0)  daily  has  been  suggested  as  a  substitute  for  its  hypodermatic  employ- 
ment. 

Dyspnoea  and  venous  congestion  of  the  face  and  upper  limbs  may  be  relieved 
by  venesection  and  if  double  abductor  paralysis  of  the  vocal  cords,  as  shown 
by  laryngoscopy,  is  responsible  for  laryngeal  oedema,  intubation  or  trache- 
otomy is  to  be  considered.  Pain  at  the  site  of  the  tumor,  especially  if  this 
is  evident  externally,  may  be  lessened  by  the  application  of  an  ice  coil  or  by 
the  application  of  an  elastic  bandage.  It  is  hardly  necessary  to  suggest  that 
the  aneurysm  under  such  circumstances  must  be  carefully  protected  from 
external  violence. 

The  pain  in  advanced  stages  of  the  disease  may  necessitate  the  exhibition 
of  morphine  hypodermatically. 

Cardiac  over-action  may  be  controlled  by  the  ice  coil  and  small  doses  of 
aconite,  or  veratrum  viride.  Cardiac  stimulants,  especially  digitalis  because 
of  its  action  in  raising  the  blood  pressure,  should  be  prescribed  with  the  great- 
est care. 

In  aneurysms  of  the  fusiform  type  or  in  the  sacculated  form  when  the  com- 
munication between  the  dilatation  and  the  vessel  from  which  it  has  originated 
is  large,  there  is  little  hope  of  cure  by  means  of  the  methods  suggested  above, 
but  the  patient  may  be  allowed  to  continue  in  his  occupation  under  the  re- 
strictions advised  in  the  section  upon  the  management  of  arteriosclerosis,  such 
as  abstention  from  muscular  and  mental  exertion,  over-eating,  etc. 

Certain  surgical  measures  may  result  in  cure  in  properly  selected  patients. 
Peripheral  aneurysm  may  be  wholly  excised  or  various  forms  of  ligation  may 
be  performed,  for  a  description  of  which  the  reader  is  referred  to  works  upon 
surgery.  Continuous  compression  in  this  form  of  aneurysm  may  be  employed 
with  success.  It  consists  in  the  obliteration  of  the  sac  by  means  of  the  pressure 
of  the  finger  for  two  to  three  days,  relays  of  students  or  nurses  being  engaged 
for  the  purpose.  Among  the  less  radical  surgical  procedvues  which  have  been 
followed  by  cure,  are  the  introduction  into  the  sac  of  considerable  lengths 
of  fine  steel  wire,  horse  hair,  catgut  or  silk.     The  object  is  to  hasten  coagu- 


THE    TREATMENT   OF    ANEURYSM.  619 

lation  by  the  presence  of  the  foreign  body.  The  statistics  of  this  method  of 
treatment  are  not  such  as  to  recommend  its  frequent  employment. 

Galvano-puncture  may  be  performed  and  is  worthy  of  trial.  The  technique 
consists-  in  introducing  two  needles  into  the  sac  through  which  a  mild  galvanic 
current  is  passed.  The  needles  must  not  be  in  contact  inside  the  tumor. 
Another  method  consists  in  the  introduction  into  the  dilatation  of  a  coil  of 
fine  gold,  silver  or  steel  wire  through  which  the  current  is  sent.  The  proced- 
ure is  not  without  danger;  embolism,  secondary  bulging  of  the  sac  wall  or 
obliteration  of  a  smaller  artery  emerging  from  the  dilatation  may  result. 

Simple  irritation  of  the  lining  of  the  sac  by  means  of  a  sterilized  needle 
which  has  been  plunged  through  its  wall  is  a  simple  and  safe  procedure. 

The  needle  may  be  left  in  place  for  twenty-four  hours,  continuous  irritation 
being  carried  on  through  the  movement  of  the  sac  with  the  cardiac  systole.  It 
must  be  remembered  that  in  undertaking  any  of  the  above  described  opera- 
tions the  most  thorough  asepsis  of  field,  instruments  and  operator's  hands 
is  essential. 

The  treatment  of  abdominal  aneurysm  should  be  carried  out  upon  lines 
similar  to  those  applicable  in  the  case  of  aneurysm  of  the  thoracic  aorta. 


620  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


CHAPTER  VIII. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

DISEASES  OF  THE  NOSE. 

ACUTE  RHINITIS. 

Synonyms.     Acute  Coryza;  Cold  in  the  Head. 

Definition.     An  acute  inflammation  of  the  nasal  mucous  membrane. 

Etiology.  It  is  probable  though  not  certain  that  germ  infection  plays 
a  part  in  the  causation  of  "cold  in  the  head"  although  the  attack  proper  is 
usually  brought  on  by  exposure,  wetting  of  the  feet,  etc. 

Pathology.  The  mucous  membrane  of  the  nose  is  first  dr}',  red  and 
swollen,  later  there  is  hypersecretion  of  thin  watery  mucus  which  later  may 
or  may  not  become  muco-purulent  and  viscid. 

Symptoms.  The  first  of  these  is  usually  a  feeling  of  fulness  in  the  head 
and  difficulty  in  breathing  through  the  nose,  the  result  of  the  hypera^mia  of 
the  nasal  lining;  sneezing  may  be  present  and  there  may  be  a  slight  elevation 
of  temperature.  After  a  number  of  hours  the  watery  nasal  discharge  appears. 
It  is  often  profuse  and  may  be  so  irritating  in  character  as  to  cause  exco- 
riations of  the  nostrils  and  upper  lip.  After  a  day  or  two  the  secretion  becomes 
thick,  yellowish  and  tenacious;  this  persists  for  a  few  days  and  then  disappears. 

Treatment.  If  taken  early,  abortive  measures  may  succeed.  These  con- 
sist in  free  purgation  by  means  of  fractional  doses  of  calomel  followed  by  a 
saline,  a  single  large  dose  of  quinine,  lo  to  15  grains  (0.66  to  i.oo),  and 
on  going  to  bed,  a  Dover's  powder  and  a  glass  of  lemonade  as  hot  as  it 
can  be  taken.  Such  means  are  likely  to  produce  free  diaphoresis  and  may 
result  in  prevention  of  further  manifestation  of  the  rhinitis.  The  early  use  of 
the  so-called  rhinitis  tablet  may  also  mitigate  the  inflammation.  Such  tablets 
may  consist  of:  Camphor  ^  grain  (0.03)  quinine  sulphate  \  grain  (0.03), 
extract  of  belladonna  ^q-  grain  (0.006),  or,  monobromated  camphor  |  grain 
(0.03),  euquinine  ^  grain  (0.03),  extract  of  hyoscyamus  yV  grain  (0.006); 
one  or  two  of  either  of  these  may  be  given  every  half  hour  until  six  have  been 
taken. 

The  hyperemia  of  the  nasal  lining  may  be  reduced  by  a  spray  of  adrenalin 
chloride,  i-iooo  solution,  one  part  to  o.g  percent,  salt  solution  eight  parts  or 
a  spray  containing  antipvrine  10  grains  (0.66),  cocaine  hydrochloride  2  grains 
(0.13),  camphor  water  3  drachms  (12.0),  water  to  i  ounce  (30.0).    Previous  to 


HAY    FEVER.  62 1 

using  either  of  these  the  nose  should  be  douched  or  sprayed  with  an  alkahne 
solution,  Dobell's  for  instance,  in  order  to  remove  any  secretion  and  to  allow 
free  contact  of  the  mediqated  spray  to  the  swollen  tissues.  Sprays  containing 
cocaine  should  rarely  be  given  to  the  patient  for  his  own  use  since  there  is 
possibility  of  the  acquirement  of  the  habitual  use  of  the  drug.  Simple  alka- 
line, mildly  antiseptic  and  oily  sprays  such  as  menthol  gr.  x  (0.66)  or  oil  of 
gaultheria,  itlv  (0.33)  to  the  ounce  (30.0)  of  albolene  may  be  used  frequently 
and  afford  much  relief;  the  inhalation  of  iodine,  2  or  3  grains  (0.12  to  0.20) 
to  the  ounce  (30.0)  of  asther  is  said  to  be  another  excellent  means  of  lessening 
the  nasal  discomfort. 

In  children  the  use  of  sprays  is  attended  with  some  difficulty  but  their  noses 
may  be  easily  cleansed  by  means  of  a  minim  dropper  and  any  simple  alka- 
line solution.  It  is  also  well  to  remember  the  irritating  effect  of  the  nasal 
discharge  and  provide  against  this  by  anointing  the  nostrils  and  upper  lip 
with  cold  cream  or  vaseline. 

The  debility  following  acute  coryza  often  is  such  that  the  exhibition  of  the 
various  tonics,  codliver  oil,  iron,  the  bitters  and  arsenic,  is  indicated. 

HAY  FEVER. 

Synonyms.  Vasomotor  Rhinitis;  Hay  Asthma;  Rose  Cold;  Autumnal 
Catarrh. 

Definition.  An  acute  catarrhal  inflammation  of  the  nasal  mucous  mem- 
brane usually  associated  with  conjunctivitis  and  asthmatic  symptoms  and 
occurring  in  the  early  summer  or  the  autumn. 

.Etiology.  The  disease  is  more  common  in  men  than  in  women  and  is 
predisposed  to  by  any  intra-nasal  lesion  such  as  chronic  inflammation,  bony 
hypertrophies,  polyps,  etc.,  and  the  neurotic  diathesis.  The  acuity  of  the 
attacks  of  this  disease  is  induced  by  the  inhalation  of  the  pollen  of  various 
plants,  irritating  dust  or  odors,  animal  emanations,  changes  of  temperature, 
nervous  shocks,  etc.  Heredity  plays  a  considerable  part  in  the  causation  of 
this  condition,  and  it  is  not  uncommon  in  patients  of  lithsemic  diathesis. 

Pathology.  This  is  merely  that  of  an  inflamed  and  hyperasmic  nasal 
mucous  membrane  superadded  in  many  cases  to  a  chronic  intra-nasal  abnor- 
mality. From  the  nasal  lining  there  is  a  profuse  watery  discharge,  the  result 
of  a  serous  exosmosis  from  the  blood-vessels  of  the  part. 

Symptoms.  The  onset  of  an  attack  often  comes  at  the  same  time,  even 
to  a  day,  of  each  season  and  may  begin  suddenly  or  gradually.  At  first 
there  is  merely  a  tickling  sensation  in  the  nose  and  mouth  often  followed  by 
uncontrollable  and  paroxysmal  sneezing.  The  nasal  mucous  membrane 
becomes  swollen  and  there  is  copious  irritating  discharge  from  the  nostrils. 
The  conjunctiva;  are  also  involved  as  is  shown  by  suffusion  and  increase  of 


622  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

lachrymal  secretion,  and  in  marked  instances  the  catarrhal  condition  may  spread 
to  the  ears  as  evidenced  by  tinnitus  and  impairment  of  hearing.  There  are 
often  severe  headache  and  marked  mental  depression. 

In  certain  patients  tlie  attack  is  characterized  by  cough,  with  or  without 
expectoration,  and  asthmatic  dyspnoea. 

Rliinoscopy  reveals  a  turgescence  of  the  nasal  lining  which  is  glossy,  opales- 
cent in  hue  and  covered  with  a  thin,  viscid  serous  secretion. 

Treatment.  With  regard  to  prophylactic  and  inter-paroxysmal  treatment 
it  is  sufficient  to  insist  that  all  pathological  intra-nasal  conditions  should 
receive  proper  treatment  by  the  rhinologist.  The  septum  and  the  turbinates, 
particularly,  should  be  carefully  examined  for  abnormality. 

The  constitutional  dyscrasia,  nervous  or  lithaemic,  should  receive  careful 
attention,  especially  for  the  month  or  so  before  an  expected  attack.  The 
former  may  be  benefited  by  combinations  of  the  zinc  salts,  belladonna,  phos- 
phorus and  arsenic.     For  the  management  of  the  latter  see  p.   263  and  ff. 

The  prevention  of  an  attack  by  change  of  climate,  when  convenient,  is 
always  advisable.  A  sea  voyage  taken  at  the  time  of  an  expected  paroxysm 
will  often  prevent  its  occurrence  as  will  residence  in  various  mountain  or  sea 
side  resorts  such  as  those  provided  by  the  White,  Catskill  and  Adirondack 
mountains  and  Beach  Haven,  N.  J.,  Nantucket,  Mount  Desert,  etc.  The 
same  climate  will  by  no  means  be  efficacious  in  all  patients,  consequently 
experimentation  may  be  necessary  before  the  proper  one  for  an  individual 
subject  is  found. 

The  local  treatment  of  the  attack  consists  in  the  use  of  various  sprays  and 
local  applications  of  which  probably  the  best  is  adrenalin  chloride.  This 
agent  acts  by  constricting  the  swollen  and  inflartied  mucous  membrane  and 
diminishing  the  secretion.  It  may  be  best  applied  by  means  of  the  nasal 
applicator  or  spray  in  strength  of  i  to  2,000  or  i  to  4,000  in  pure  olive  oil.  An 
oily  solution  of  i  to  1,000  strength  is  obtainable  and  may  be  diluted  as  the 
patient  requires.  Before  the  use  of  the  oily  solution  the  nasal  mucous  mem- 
branes should  be  cleansed  of  secretion  by  means  of  an  alkaline  spray. 

Cocaine  sprays  or  applications,  2  to  4  percent,  in  strength,  are  useful  but 
the  danger  of  engendering  the  cocaine  habit  renders  their  routine  employ- 
ment ill-advised. 

Suprarenal  extract  may  also  be  given  internally  in  doses  of  5  to  10  grains 
(0.33  to  0.66)  every  two  hours  during  an  attack  but  should  be  stopped  as  soon 
as  the  physiological  action  of  the  drug,  as  evidenced  by  palpitation  or  vertigo, 
is  noted.  When  these  symptoms  have  disappeared  the  extract  may  be  again 
administered  in  less  frequent  dosage,  every  three  or  four  hours  for  instance, 
and  the  intervals  gradually  increased  as  the  nasal  symptoms  become  ameli- 
orated. 

Quinine  in  doses  of  10  to  20  grains  (0.66  to  1.33)  a  day  may  be  given  during 


ACUTE    CATARRHAL    LARYNGITIS.  623 

an  attack  and  belladonna  and  potassium  iodide  are  said  to  be  of  benefit  at 
times.  The  nervousness  and  restlessness  to  which  patients  suffering  from 
an  attack  of  hay  fever  are  prone  may  be  controlled  by  the  bromides,  hyoscya- 
mus  or  chloral,  and  the  conjunctivitis  may  be  relieved  by  the  application 
of  a  saturated  solution  of  boric  acid  or  by  dropping  into  the  eyes  every  two 
hours  a  drop  or  two  of  the  following  formula:  Zinc  sulphate,  i  grain 
(0.065);  camphor  water,  i  drachm  (4.0);  saturated  solution  of  boric  acid  to 
I  ounce  (30.0). 

Recently  there  has  been  an  attempt  to  elaborate  antitoxins  from  the  pol- 
lens of  certain  plants,  notably,  ragweed  and  golden-rod,  which  may  be  used 
as  immunizing  agents,  and  Dunbar  asserts  that  he  has  prepared  an  effi- 
cacious serum  by  inoculating  horses  with  a  substance  prepared  from  pollen 
and  drawing  from  them  the  blood-serum.  This  antitoxin  may  be  used  in  its 
fluid  form,  or  dried  to  a  powder,  as  a  snuff,  and  excellent  results  are  reported 
from  its  employment. 

DISEASES  OF  THE  LARYNX. 
ACUTE  CATARRHAL  LARYNGITIS. 

.Etiology.  Acute  laryngitis  may  be  caused  by  exposure  to  cold  and  wet, 
or  by  the  inhalation  of  irritating  gases  or  dust.  It  is  predisposed  to  by  exces- 
sive smoking,  the  abuse  of  alcohol,  excessive  use  of  the  voice  and  by  previous 
attacks.  It  may  complicate  the  acute  infectious  diseases.  With  it  are  fre- 
quently associated  catarrhal  inflammations  of  the  nose,  throat,  trachea  and 
bronchial  tubes. 

Pathology.  Early  in  the  inflammation  the  mucous  membrane  lining  the 
larynx  is  reddened,  congested  and  dry,  after  about  twenty-four  hours  there  is 
an  increased  exudation  of  mucus  and  a  diminution  of  the  redness  and  con- 
gestion; examination  by  means  of  the  laryngoscope  reveals  swelling  and  red- 
ness of  the  lining  of  the  larynx  and  of  the  true  and  false  vocal  cords. 

Symptoms.  Of  these  the  most  prominent  is  hoarseness;  the  voice  is  husky, 
reduced  to  a  whisper,  or  lost.  There  is  cough,  at  first  dry  and  husky,  later 
with  the  expectoration  of  mucus.  At  times  it  may  be  stridulous.  There 
may  be  pain  in  the  larynx  which  is  increased  on  swallowing  and  in  the  severer 
instances  there  is  a  moderate  rise  of  temperature.  Dyspnoea  may  be  present. 
This  symptom  varies  in  intensity  from  time  to  time  and  in  rare  instances 
respiration  may  cease  and  death  result.  Instances  complicated  by  oedema  of 
the  glottis  also  suffer  from  dyspnoea  depending  upon  the  degree  of  the  oedema. 
Usually  the  disease  lasts  from  ten  days  to  two  weeks.     Recovery  is  the  rule. 

Treatment.  In  the  milder  instances  the  patient  need  not  be  confined  to  bed 
nor  need  the  diet  be  restricted,  but  he  should  be  kept  in  a  slightly  damp 


624  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

atmosphere  at  a  temperature  from  70°  to  75°  F.  (20.5°  to  24.0°  C.)-  The 
pain  and  discomfort  may  be  relieved  by  the  application  of  hot  or  cold  com- 
presses or  the  ice  coil  to  the  throat.  The  cough  may  be  controlled  by  the 
following  formula:  I^  codeinae,  gr.  v  (0.33);  aquae  amygdalae  amaras,  5ss 
(15.0).  Misce  et  signa  5  to  15  drops  (0.33  to  i.oo)  every  two  hours;  small  doses, 
gr.  i^  (o.io)  of  Dover's  powder  are  also  useful.  The  dryness  of  the  mucous 
membrane  and  the  hoarseness  may  be  rendered  less  distressing  by  the  adminis- 
tration of  tartar  emetic  in  doses  of  j^q-  to  -^^  (0.0006  to  0.0012)  of  a  grain. 
As  a  sedative  inhalation  the  following  formula  may  be  employed.  I^  potassii 
bromidi,  gr.  x  (0.66);  cocainag  hydrochloridi,  gr.  v  (0.33);  aquae  destillatae,  3v 
(20.0). 

Frequent  inhalations  of  medicated  steam  often  afford  relief.  Many  sub- 
stances have  been  used  a  few  of  which  are  appended.  Compound  tincture 
of  benzoin  i  to  128  of  boiling  water.  Compound  tincture  of  benzoin  and 
paregoric  of  each  i  part  to  128  parts  of  boiling  water.  Turpentine  and 
eucalyptus  may  be  used  in  the  same  fashion. 

As  the  acuity  of  the  inflammation  subsides  applications  of  tannin  or  alum 
mixed  with  an  equal  quantity  of  starch,  should  be  made  to  the  larynx,  by 
means  of  the  powder  blower,  or  astringent  sprays,  such  as  zinc  sulphate, 
gr.  XXX  (2.00)  or  zinc  chloride,  gr.  xv  (i.o)  to  the  ounce  (30.0)  of  water  or 
liquor  antisepticus  or  tincture  of  iron  chloride,  rr|xxx  (2.00)  to  the  ounce  (30.0) 
of  water,  should  be  employed. 

In  the  prolonged  instances  change  of  climate  and  the  administration  of  tonics 
are  indicated. 

SIMPLE  CHRONIC  CATARRHAL  LARYNGITIS. 

.etiology.  Chronic  catarrhal  laryngitis  may  be  the  result  of  any  of  the 
causes  predisposing  to  acute  laryngitis,  such  as  abuse  of  the  voice  in  public 
speaking  or  singing,  and  it  may  follow  repeated  attacks  of  acute  laryngitis. 
It  is  also  predisposed  to  by  nasal  obstruction. 

Pathology.  Examination  of  the  larynx  reveals  moderate  swelling  of  the 
vocal  apparatus,  the  mucous  membrane  is  yellowish-red  in  color,  the  vocal 
cords  are  thickened,  their  edges  are  irregular  and  there  is  thickening  of  the 
mucous  membrane  lining  the  posterior  commissure.  Ulcers  or  erosions, 
when  present  always  bilateral,  may  be  observed  over  the  processus  vocalis. 
Either  or  both  of  the  vocal  cords  may  be  relaxed. 

Symptoms.  Of  these  the  most  noticeable  is  hoarseness  which  may  vary 
from  a  slight  huskiness  of  the  voice  to  almost  complete  aphonia.  Use  of 
the  voice  may  cause  pain.  Cough,  due  to  laryngeal  irritation  is  a  frequent 
symptom,  and  the  patient  may  raise  mucoid  or  muco-purulent  sputum  in  small 
or,  at  most,  moderate  quantity. 


SIMPLE    CHRONIC    CATARRHAL    LARYNGITIS.  625 

Treatment.  Persons  subject  to  throat  disorders  should  avoid  undue  ex- 
posure to  cold  and  wet  and  excessive  use  of  the  voice.  The  abuse  of  alcoholic 
beverages  and  tobacco  should  be  forbidden  and  the  patient  warned  against 
the  inhalation  of  dust  and  irritating  vapors.  In  this  connection  the  wearing 
of  a  respirator  may  be  recommended,  and,  if  convenient,  a  change  of  climate 
advised. 

Any  constitutional  condition  which  may  influence  the  local  lesion  should 
receive  appropriate  treatment,  and  all  functional  disturbances — digestive, 
etc. — should  be  regulated,  as  well  as  all  pathological  conditions  of  the  nasal, 
naso-pharyngeal,  or  pharyngeal  structures. 

The  local  inflammation  may  be  best  treated  by  astringent  sprays  such  as 
the  following:  Zinc  chloride  or  sulphate  30  grains  (2.0)  to  the  ounce  (30.0) 
of  water  or  liquor  antisepticus;  iron  and  ammonium  sulphate  one  drachm 
(4.0),  or  silver  nitrate  10  grains  (0.66),  or  tincture  of  iron  chloride  one  to  two 
drachms  (4.0  to  8.0)  to  the  ounce  (30.0)  of  water;  2  to  3  percent,  solutions 
of  alum  or  I  to  2  percent,  tannic  acid  solutions  are  also  useful.  While  the 
larynx  is  being  sprayed  the  patient  should  be  directed  to  inhale  so  that  the 
medicament  may  be  drawn  into  contact  with  the  inflamed  area;  also  it  should 
be  remembered  that  in  order  that  the  application  may  have  its  full  effect, 
the  larynx  should  be  sprayed  with  an  alkaline  solution  (dilute  liquor  anti- 
septicus for  example)  before  the  use  of  the  astringent. 

Long  standing  instances  with  considerable  hypertrophy  of  the  tissues  may  be 
benefited  by  sprays  of  zinc  iodide  15  grains  (i.o)  to  the  ounce  of  water  or 
liquor  antisepticus  or  of  such  a  mixture  as  the  following:  I^  iodi,  gr.  iv  (0.24); 
potassii  iodidi,  gr.  x  (0.66);  zinci  iodidi,  gr.  xx  (1.33);  zinci  phenolsulphonatis, 
gr.  XX  (1.33);  liquoris  antiseptici,  oiv  (120.0). 

Applications  by  means  of  a  brush  are  useful  and  any  of  the  above  astringents 
added  to  a  half -ounce  (15.0)  each  of  glycerin  and  water  may  be  used.  A 
ID  percent,  resorcinol  solution  may  also  be  applied  by  this  means. 

Such  applications  as  the  above  should  be  made  daily  at  first,  but  later  the 
interval  may  be  lengthened,  depending  upon  the  success  of  the  treatment. 

The  use  of  medicated  steam  inhalations  such  as  those  described  under  the 
treatment  of  acute  laryngitis  (p.  624)  may  be  advisable,  or  solutions  of  alum  i 
to  10  grains  (0.065  to  0.66),  iron  perchloride,  2  to  5  grains  (0.13  to  0.33)  or 
zinc  sulphate  i  to  5  grains  (0.065  to  0.33)  to  the  ounce  (30.0)  of  water  may 
be  employed  in  the  same  manner. 

Lozenges  or  troches  may  be  employed  for  local  effect  and  they  may  also 
have,  through  the  stimulation  of  the  mucous  membrane  of  the  throat,  a  reflex 
action  upon  the  larynx.  The  drugs  which  may  be  used  by  this  means  are 
cubeb,  ammonium  chloride,  benzoic  acid,  guaiac,  rhatany,  potassium  chlorate 
and  lactucarium.  An  astringent  troche  consisting"  of  tannic  acid  i  grain 
(0.065),  gallic  acid,  catechu  and  kino  each  2  grains  (0.13),  is  often  useful  and 
40 


626  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

convenient  where  for  any  reason  local  treatment  by  sprays  or  direct  applica- 
tion is  not  readily  applicable.  When  irritating  cough  is  present  tablets  of 
heroine — ^^  to  yV  of  a  grain  (0.0027  to  0.0055) — may  be  prescribed. 

Powder  insufflation  is  found  useful  in  many  patients.  Powders  of  equal 
parts  of  alum  and  starch,  tannic  acid  and  starch  or  borax  and  starch  may  be 
employed  as  well  as  sedative  powders  such  as  morphine  acetate  2  to  10  grains 
(0.13  to  0.66)  to  iodoform  4  drachms  (15.0). 

Gargles  are  less  effective  than  the  foregoing  means  since  it  is  very  difficult 
to  reach  the  site  of  the  lesion  by  this  form  of  treatment.  They  may  be  em- 
ployed, however,  if  considered  advisable,  and  may  consist  of  alum,  i  drachm 
(4.0);  zinc  chloride,  §  drachm  (2.0);  zinc  phenolsulphonate,  2  drachms  (8.0); 
potassium  chlorate,  2  drachms  (8.0);  phenol,  20  grains  (1.33);  acetic  acid,  2 
drachms  (8.0)  or  boric  acid,  4  drachms  (15.0)  to  8  ounces  (250.0)  of  water. 

SPASMODIC  LARYNGITIS. 

Synonyms.  Catarrhal  Spasm  of  the  Larynx;  False  Croup;  Spasmodic 
Croup. 

Definition.  An  acute  catarrhal  inflammation  of  the  laryngeal  mucous 
membrane  accompanied  by  a  spasm  of  the  laryngeal  muscles. 

.Etiology.  This  condition  occurs  in  children  from  six  months  to  five  years 
of  age;  it  is  rarely  met  later.  It  is  predisposed  to  by  the  presence  of  adenoids 
and  enlarged  tonsils,  the  breathing  of  over-heated  or  impure  air  and  certain 
children  seem  more  prone  to  attacks  than  others.  The  exciting  cause  is  usu- 
ally exposure  to  cold  or  a  digestive  disturbance. 

Patliology.  The  mucous  lining  of  the  larynx,  especially  that  part  above 
the  true  vocal  cords,  is  red  and  congested,  later  there  is  an  excessive  secretion 
of  mucus.  At  the  time  of  the  attack  there  is  superimposed  upon  the  inflam- 
matory condition  a  spasm  of  the  laryngeal  muscles,  particularly  the  adductors. 

Symptoms.  During  the  day  the  patient  suffers  from  little  except  slight 
hoarseness  and  nasal  discharge.  The  laryngeal  spasm  usually  occurs  at 
night  and  often  without  warning.  There  is  difficult  and  stridulous  breathing 
and  a  croupy  cough;  at  times  the  dyspnoea  is  so  great  that  the  child  is  in  marked 
distress,  the  accessory  muscles  of  respiration  come  into  play,  the  face  and 
extremities  may  become  livid  and  the  condition  seems  very  alarming  to  the 
casual  observer.  There  is  rarely  more  than  a  slight  febrile  movement.  The 
paroxysm  lasts  for  several  hours.  During  the  following  day  the  patient  docs 
not  appear  ill  but  the  attack  is  likely  to  return  for  two  or  three  nights,  unless 
prevented  by  treatment,  after  which  the  symptoms,  other  than  moderate 
hoarseness  or  cough,  disappear.  The  condition,  although  distressing  while 
it  lasts,  is  never  fatal. 

Treatment.     Prophylactic  treatment  consists  in  the  removal  of  adenoids 


TUBERCULOUS    LARYNGITIS.  62/ 

and  hypertrophied  tonsils,  attention  to  the  condition  of  the  digestion  and  to 
the  diet  and  general  hygiene  of  the  patient. 

The  laryngeal  spasm  may  be  relieved  by  em^sis  which  may  be  brought  about 
by  the  administration  of  wine  of  ipecac  in  doses  of  ^  to  i  drachm  (2.0  to  4.0) 
every  five  or  ten  minutes  until  effective,  or  of  tartar  emetic  and  powdered 
ipecac  each  y|o  of  a  grain  (0.0006) ;  the  latter,  however,  should  be  repeated 
with  caution  because  of  the  depressing  effect  of  the  antimony.  Repeated 
doses  of  alum  (gr.  5 — 0.33)  in  a  little  syrup  or  molasses  are  also  an  excellent 
emetic.  Not  only  does  the  emesis  relieve  the  spasm  of  the  laryngeal  muscles 
but  if  the  attack  is  due  to  digestive  disturbance  it  relieves  the  stomach  of  any 
irritating  contents. 

If  constipation  is  present  the  bowels  should  be  emptied  by  means  of  an 
enema.  Further  attacks  may  be  prevented  by  the  administration  of  anti- 
pyrine  of  which  a  child  of  two  years  may  receive  2  grains  (0.13)  every  four 
hours  for  two  or  tliree  doses.  During  the  next  day  the  ipecac  and  tartar  emetic 
may  be  continued  in  dosage  given  above  every  four  hours  and  the  tendency  to 
a  paroxysm  during  the  next  nights  may  be  combated  by  giving  a  dose  of  anti- 
pyrine  at  bed  time.  The  inhalation  of  steam  from  a  croup  kettle,  the  child 
being  in  a  tent  made  by  pinning  blankets  over  its  crib,  is  an  excellent  means 
of  treating  the  laryngeal  inflammation.  To  the  water  in  the  kettle  a  drachm 
(4.0)  of  compound  tincture  of  benzoin  or  of  oil  of  eucalyptus  or  five  grains 
(0.33)  of  menthol  may  be  added.  Hot  or  cold  compresses  or  poultices  of 
flax  seed  or  very  weak  mustard  may  be  applied  over  the  larynx  with  good 
effect  and  to  relieve  the  excitability  of  the  patient,  5  to  10  grains  of  sodium 
bromide  (0.33  to  0.66)  may  be  given. 

Patients  which  resist  ordinary  treatment  may  be  temporarily  intubated. 

TUBERCULOUS  LARYNGITIS. 

.Etiology.  This  affection  may  be  primary  or  secondary.  Rarely,  however, 
is  the  former  the  case  since  the  laryngeal  tissues  seem  not  to  afford  a  favorable 
site  for  the  growth  and  development  of  the  tubercle  bacillus.  More  fre- 
quently is  the  disease  secondary  to  tuberculous  infection  of  the  lungs,  bacilli 
from  the  sputum  finding  lodgment  and  setting  up  the  inflammation.  Laryn- 
geal involvement  is  said  to  occur  in  about  twenty  percent,  of  instances  of 
pulmonary  tuberculosis. 

Pathology.  The  first  stage  of  tuberculous  laryngeal  inflammation  is  an 
anaemia  of  the  tissues  due  to  the  occlusion  of  the  blood-vessels  of  the  part  con- 
sequent upon  the  growth  of  new  tuberculous  tissue.  This  is  followed  by  a 
thickening  resulting  from  further  growth  of  and  infiltration  by  this  tissue. 
This  infiltration  is  especially  noticeable  over  the  arytenoid  cartilages,  in  the 
posterior  commissure,  on  the  edges  of  the  vocal  cords  and  upon  the  epiglottis. 


628  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

The  stage  of  infiltration  usually  lasts  about  a  week  and  is  followed  by  ulcera- 
tion. The  ulcers  occur  in  the  same  situations  as  the  infiltration.  They  are 
shallow,  their  color  is  that  of  the  surrounding  parts  with  which  their  edges 
are  flush,  there  are  few  signs  of  acute  inflammation  and  the  ulcerating  sur- 
faces are  covered  with  a  ropy  semi-opaque  mucus.  The  final  stage  of  the 
morbid  process  is  necrosis. 

It  must  be  remembered  that  not  all  inflammations  of  the  larynx  which 
occur  in  tuberculous  patients  are  due  to  the  specific  infection  of  the  disease. 

Symptoms.  These  are  engrafted  upon  those  of  the  primary  inflammation 
of  the  lungs  if  this  be  present.  The  first  symptom  calling  attention  to  the 
larynx  is  hoarseness  which  increases  even  to  entire  loss  of  voice.  This  is 
due  during  the  stage  of  infiltration  to  the  impossibility  of  approximation  of 
the  vocal  cords  as  a  result  of  this  condition,  later  it  is  due  to  the  ulceration. 
In  this  stage  the  voice  is  permanently  lost  and  the  patient  can  but  whisper. 
Dysphagia  is  also  a  characteristic  symptom,  though  a  later  one,  and  does  not 
appear  until  the  ulceration  has  spread  beyond  the  laryngeal  cavity.  The 
pain  is  often  very  severe  when  the  swallowing  of  food  is  attempted  and  the 
patient's  state  is  most  pitiable.  There  are  rapid  emaciation  and  loss  of  strength 
and  the  chances  for  recovery  are  distinctly  not  good.  In  instances  where  the 
laryngeal  condition  is  priniary  the  course  of  the  disease  is  likely  to  be  more 
rapid  than  in  those  secondary  to  pulmonary  disease. 

Treatment.  The  treatment  of  this  condition  consists  in  the  employment 
of  aU  means  in  our  power  to  sustain  the  patient  and  to  improve  his  general 
condition,  just  as  in  pulmonary  tviberculosis  uncomplicated  by  laryngeal 
disease,  in  the  medicinal  treatment  of  the  pulmonary  lesions  (see  p.  178) 
and  in  the  local  treatment  of  the  laryngeal  lesion.  This  last  consists  of  thor- 
ough cleansing  of  the  laryngeal  mucous  membrane  by  means  of  a  spray  of 
an  alkaline  and  antiseptic  solution  such  as  the  following:  I^  sodii  boratis, 
sodii  bicarbonatis,  aa  5i  (4-o);  glyceriti  phenolis,  5ii  (8.0);  aquae,  5viii 
(250.0),  followed  by  astringent  sprays  such  as  zinc  chloride  5  grains  (0.33)  to 
the  ounce  (30.0)  of  water.  The  inhalation  of  medicated  steam  (see  p.  624) 
or  of  the  vapor  of  i  to  5  percent,  phenol,  i  percent,  lysol  or  i  percent,  creolin 
solutions  may  be  employed. 

The  pain  may  be  eased  by  the  inhalation  of  analgesic  powders,  or  sprays 
such  as  morphine  acetate  5  to  10  grains  (0.33  to  0.66)  to  the  drachm  (4.0) 
of  starch;  morphine  sulphate  5  to  10  grains  (0.33  to  0.66)  to  the  ounce  (30.0 
of  water,  or  morphine  hydrochloride  15  grains  (i.o),  sodium  bicarbonate 
45  grains  (3.0),  to  6  ounces  (180.0)  of  water. 

When  ulceration  has  taken  place  the  insufflation  of  morphine  sulphate 
10  grains  (0.66),  tannic  acid  2  drachms  (8.0),  iodoform  6  drachms  (24.0),  or 
morphine  hydrochloride  7^  grains  (0.50),  iodoform  and  starch  of  each  75  grains 
(5.0),  is  useful  as  well  as  a  spray  of  20  grains  of  menthol  (1.33),  to  the  drachm 


CEDEMA    OF    THE    GLOTTIS.  629 

(4.0)  of  olive  oil.  To  lessen  the  pain  attendant  upon  the  swallowing  of  food 
the  throat  should  be  anccsthetized,  after  an  alkaline  cleansing  spray,  by  a  spray 
of  cocaine  hydrochloride  5  to  10  grains  (0.33  to  0.66),  water  a  half  drachm 
(2.0),  to  which  an  ounce  (30.0)  of  albolene  is  added,  or  by  direct  application 
by  means  of  the  laryngeal  brush  of  a  10  to  15  percent,  cocaine  solution.  Such 
a  procedure  will  bring  about  an  anaesthesia  lasting  from  ten  to  fifteen  minutes 
during  which  the  patient  can  eat  in  comparative  comfort. 

It  is  often  advisable  to  feed  by  means  of  the  stomach  tvibe  and  forced  feed- 
ing by  gavage  often  accomplishes  excellent  results.  The  food  is  prepared 
as  follows:  Lean  meat  from  which  all  the  tendon  and  gristle  and  as  much 
of  the  fat  as  is  possible  have  been  removed  should  be  used.  The  meat  is  to  be 
finely  chopped  and  dried  in  an  oven  at  150°  F.  (66°  C.)  until  it  has  become 
absolutely  dried.  The  oven  temperature  is  now  raised  to  170°  F.  (77°  C.) 
and  the  powdered  meat  allowed  to  remain  for  several  hours;  it  is  then  ground 
in  a  mortar  and  sifted.  Six  parts  of  raw  meat  thus  treated  will  furnish  about 
one  part  of  beef  powder. 

After  cocainization  of  the  throat  and  larynx  the  tube  is  passed,  the  stomach 
is  washed  with  a  pint  Q  litre)  of  artificial  Vichy  water  and  the  patient  is 
fed  by  pouring  through  the  tube  f  of  a  pound  (312.0)  of  the  beef  powder 
to  which  three  times  as  much  milk  has  been  added.  At  first  such  a  meal 
should  be  given  twice  a  day  and  the  amount  gradually  increased  until  the 
patient  takes  from  i  to  2  (450.0  to  900.0)  pounds  of  the  powder  and  4  or  5 
pints  of  milk  (2000.0  to  2250.0)  per  day.  If  there  is  difficulty  in  digesting 
this  the  milk  may  be  omitted  and  a  little  dilute  hydrochloric  acid,  with  suffi- 
cient water,  added  to  the  meat  powder. 

Surgical  treatment  is  contraindicated  when  the  pulmonary  and  laryngeal 
inflammations  are  advanced  and  progressing,  it  may  be  employed  when  the 
laryngeal  disease  is  quiescent  and  there  is  no  progressive  destruction  of  tissue 
or  perichondritis.  For  the  technique  of  the  various  operations  applicable 
the  reader  is  referred  to  special  works  upon  the  subject. 

(EDEMA  OF  THE  GLOTTIS. 

Definition.  A  submucous  serous  transudate  into  the  tissues  surrounding 
the  laryngeal  opening. 

.Etiology.  This  condition  may  complicate  acute  or  chronic  inflammations 
of  the  larynx,  acute  infectious  diseases  such  as  typhoid  fever  or  smallpox,  or 
any  constitutional  condition  of  which  oedema  is  a  feature,  notably  cardiac  and 
renal  disease.  The  affection  may  occur  at  any  period  of  life  but  is  less  com- 
mon in  children.  The  transudation  of  the  serum  takes  place  into  the  sub- 
mucosa  of  the  aryteno-epiglottidean  folds,  of  the  epiglottis  or  of  the  ventric- 


630  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

ular  bands,  and  may  be  so  marked  as  to  entirely  close  the  superior  opening 
of  the  larynx. 

(Edema  of  the  glottis  may  also  result  from  the  inhalation  of  irritating  vapors 
or  from  the  swallowing  of  caustic  fluids  and  rarely  from  ivy  poisoning. 

Symptoms.  Of  these  the  most  prominent  is  a  sensation  of  oppression, 
which  may  be  intensified  to  actual  suffocation.  The  face  is  anxious,  there 
may  be  cyanosis  of  the  lips  and  extremities  and  there  is  visible  action  of  the 
accessory  muscles  of  respiration.     The  breathing  is  rapid  and  stridulous. 

Treatment.  The  milder  instances  in  which  the  distress  is  but  moderate  may 
be  relieved  by  depletion  by  means  of  a  hydrogogue  cathartic  such  as  magnesium 
sulphate  or  citrate  and  the  inhalation  of  steam  which  may  be  medicated  by 
the  addition  of  a  little  compound  tincture  of  benzoin  or  menthol.  Astringent 
sprays  such  as  alum  i  part,  to  24  of  water,  or  alumnol  i  to  ij  parts  to  24  of 
water  may  be  employed.  Leeches  or  blisters  over  the  larynx  may  relieve  the 
milder  degrees  of  this  condition.  Cold  applied  in  the  form  of  compresses  to 
the  neck  or  by  means  of  ice  bags  or  coils  is  an  excellent  remedy  and  it  may  be 
applied  internally  as  well,  by  giving  the  patient  pieces  of  ice  to  hold  in  the 
mouth.  Pilocarpine  in  dosage  of  J  of  a  grain  (0.016)  given  hypodermati- 
cally  is  said  to  have  achieved  excellent  results  but  the  drug  should  be  used  with 
caution  especially  if  the  heart  tends  toward  weakness,  since  it  may  bring  about 
oedema  of  the  lungs. 

Hot  packs  may  be  given  but  unless  the  therapeutic  methods  above  described 
succeed  in  ameliorating  the  condition,  scarification  of  the  infiltrated  tissue  will 
will  usually  be  found  necessary.  In  the  markedly  acute  instances  in  which  the 
patient  is  in  extremis  from  the  first  the  physician  should  be  prepared  to  per- 
form intubation  or  tracheotomy,  preferably  the  former,  at  a  moment's  notice. 

DISEASES  OF  THE  TRACHEA  AND  BRONCHI. 
ACUTE  BRONCHITIS. 

Synonyms.     Acute  Bronchial  Catarrh;  Acute  Catarrhal  Bronchitis. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of  the  trachea 
and  bronchi  usually  accompanied  by  cough  and  more  or  less  expectoration. 

.etiology.  This  disease  is  most  common  in  cold  and  damp  climates  and 
in  the  winter  months.  Dwellers  in  cities  seem  to  be  more  prone  to  bronchitis 
than  those  living  in  the  country.  Some  persons  appear  to  have  a  predis- 
position to  attacks  of  the  disease.  Exposure  to  cold  and  dampness,  the  breath- 
ing of  irritating  fumes,  dust,  and  of  certain  toxic  bacteria  may  be  classed  as 
exciting  causes.  Frequently  the  affection  follows  an  acute  cold  in  the  head, 
the  inflammation  extending  downward  from  the  upper  air  passages  to  the 


ACUTE    BRONCHITIS.  63 1 

trachea  and  bronchi.  It  often  occurs  as  a  compUcation  of  the  infectious 
diseases,  especially  measles,  influenza,  typhoid  fever,  etc. 

Pathology.  The  mucous  membrane  lining  the  trachea  and  larger  bronchi 
— more  rarely  that  lining  the  smaller  bronchi — is  hyperaemic  and  swollen. 
At  first  the  secretion  of  mucus  is  diminished,  later  it  is  increased  and  a  tough 
exudate  covers  the  bronchial  mucous  membrane.  There  are  desquamation 
of  the  epithelial  cells  lining  the  bronchi,  emigration  of  leucocytes  and  diape- 
desis  of  red  cells.  If  the  inflammation  continues,  a  round  celled  infiltration 
occurs  in  the  peri-bronchial  tissue,  which  m.ay  be  termed  a  peri-bronchitis  and 
is  likely  to  result  in  a  permanent  pathological  condition,  a  fibroid  phthisis  or 
chronic  interstitial  pneumonia,  the  latter  term  being  preferable. 

Symptoms.  The  severer  instances  may  be  ushered  in  by  a  chill  followed  by 
a  rise  in  temperature  which  may  continue  throughout  the  course  of  the  disease. 
Usually  the  fever  is  not  above  101°  F.  (38.5°  C.)  but  it  may  rarely  reach  a 
height  of  103°  F.  (39.5°  C.)  to  104°  F.  (40.0°  C).  The  pulse  rate  is  moderately 
increased  and  the  respiration  may  be  accelerated.  There  may  be  dyspnoea 
of  varying  degree  due  to  the  decrease  in  the  calibre  of  the  bronchi  resulting 
from  the  swelling  of  their  linings  and  from  the  exudation  of  mucus.  There 
is  cough,  at  first  dry,  later  with  mucoid  or  muco-purulent  sputum,  which 
rarely  may  contain  a  little  blood.  There  may  be  pain  in  the  chest.  The 
disease  usually  lasts  from  four  or  five  days  to  two  weeks,  the  cough,  sputum 
and  other  symptoms  gradually  disappearing,  but  at  times  a  longer  course 
occurs. 

Physical  Signs.  These  depend  upon  the  degree  and  stage  of  the  inflam- 
mation. In  the  milder  instances,  no  physical  signs  whatever  may  be  obtainable. 
In  those  of  more  severe  t\^e,  the  respiration  may  be  accelerated.  The  per- 
cussion note  remains  unchanged. 

On  auscultation  sibilant  and  sonorous,  coarse  and  subcrepitant  rales  in 
varying  number  are  heard,  the  voice  as  a  rule,  remaining  unchanged.  If 
the  condition  passes  on  to  one  of  chronic  interstitial  pneumonia  the  elasticity 
of  the  lung  is  diminished  and  a  prolonged  inspiratory  and  expiratory  murmur, 
with  increased  intensity  of  the  former  and  of  the  vocal  resonance,  may  be 
detected. 

Prophylaxis.  Patients  subject  to  frequent  attacks  of  acute  bronchitis 
may,  in  great  measure,  prevent  their  occurrence  by  means  tending  toward 
a  properly  hygienic  mode  of  life.  Patients  in  the  acute  stage  of  the  disease 
should  be  confined  to  their  rooms  but  it  is  important  to  see  that  the  rooms 
are  well  ventilated  and  that  the  air  contains  the  proper  amount  of  moisture. 
An  instrument  called  the  psychrometer  may  be  used  to  determine  the  quantity 
of  moisture,  which  should  be  about  70  percent.,  in  the  atmosphere  of  the 
apartment  and  the  regulation  of  the  moisture  may  be  accomplished  by  ven- 
tilation if  it  is  too  great  or  by  sprays  of  water  or  by  means  of  evaporation  from 


632  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

water  contained  in  open  vessels  if  it  be  too  small.  After  the  acuity  of  the 
attack  is  over  the  patient,  especially  if  there  be  any  predisposition  to  the  disease, 
may  be  advised  to  seek  a  mild  climate.  Certain  patients  do  well  in  sea  air, 
others  do  better  inland.  The  salt  in  the  sea  air  has  no  especial  influence 
but  the  atmosphere  near  the  ocean,  owing  to  its  large  content  of  moisture 
and  the  fact  that  it  is  seldom  at  rest,  is  especially  beneficial  to  many  patients. 
Such  resorts  as  Lakewood  and  Atlantic  City  may  be  suggested. 

Hardening  processes,  especially  among  the  more  enlightened  classes  are 
coming  more  and  more  into  vogue,  and  rightly  so  when  they  are  properly 
carried  out;  a  morning  bath  beginning  at  from  90°  to  95°  F.  (31°  to  35°  C.) 
and  gradually  lowered,  taking  into  consideration  the  season  and  the  reaction 
of  the  patient,  is  often  of  considerable  benefit  in  this  connection. 

The  clothing  is  an  important  consideration  and  should  be  adapted  to 
the  condition  of  the  weather.  In  a  changeable  climate  in  order  to  be  properly 
clothed  one  must  often  vary  the  weight  of  the  underclothing  from  day  to  day; 
warm  garments  of  light  weight  are  always  to  be  preferred. 

As  far  as  diet  is  concerned  it  is  difficult  to  make  hard  and  fast  rules.  The 
digestion  of  the  patient  must  be  considered  and  food  easily  digested  and 
assimilated  and  at  the  same  time  nourishing  should  be  prescribed.  Cod- 
liver  oil,  when  well  borne,  is  often  beneficial. 

Many  patients  will  be  found  for  whom  a  change  of  climate  is  impossible. 
These  should  be  warned  against  mouth  breathing  and  instructed  in  the  proper 
ventilation  of  their  living  and  sleeping  rooms.  Persons  whose  occupations 
compel  them  to  spend  considerable  periods  in  an  atmosphere  contaminated 
by  dust  may  wear  respirators. 

Treatment.  During  the  febrile  stage  of  the  disease  it  is  best  to  confine  the 
patient  to  bed  in  a  well  ventilated  room.  The  diet  should  be  light  and  easily 
digestible. 

The  object  of  our  treatment  should  be  to  cure  the  inflammation  as 
quickly  as  possible  in  order  that  the  condition  may  not  go  on  and  result 
in  a  chronic  interstitial  pneumonia.  Early  in  the  disease  when  the  sputum 
is  scanty  and  difficult  to  raise  an  expectorant  is  indicated.  Of  this  class  of 
drugs  probably  the  most  active  which  we  possess  is  apomorphine  hydro- 
chloride; its  expectorant  dose  is  about  -^2  of  a  grain  (0.002)  and  if  the 
drug  is  pure  no  emetic  effect  need  be  feared.  In  twenty  minutes  after  its 
administration,  in  a  chest  where  none  were  previously  heard,  numerous  coarse 
and  fine  rales  may  be  detected  and  the  patient  will  begin  to  expectorate  watery 
sputum  in  profuse  quantity.  The  apomorphine  may  be  prescribed  as  follows: 
I^  apomorphinae  hydrochloridi,  gr.  ss  (0.03);  sodii  bromidi,  '^m  (12.0);  tinc- 
turae  sanguinariae,  §ss  (15.0);  syrupi  tolutani,  §ii  (60.0).  Misce  et  signa  i  tea- 
spoonful  (4.0)  in  a  wineglass  (60.0)  of  water  every  two  hours.  This  prescrip- 
tion is  not  applicable  in  senile  bronchitis  nor  in  the  bronchitis  of  children 


ACUTE    BRONCHITIS.  633 

save  in  very  small  doses.  Under  this  treatment  if  the  patient  is  seen  on  the 
first  day  of  his  bronchitis  he  should  be  well  within  three  or  four  days. 

If  the  patient  does  not  consult  the  physician  until  the  bronchitis  is  advanced 
and  the  secretion  thick  and  muco-purulent  the  following  formula  will  be  found 
useful,  r^  fluidextracti  cocillanae,  gss  (15.0);  fiuidextracti  lippiae  Mexican^e, 
§i  (30.0).  Misce  et  signa  ^  teaspoonful  (2.0)  in  a  wineglass  (60.0)  of  water 
every  two  hours.  Cocillana  is  in  this  dosage  a  pure  expectorant  and  stimulates 
markedly  the  muciparous  glands  of  the  bronchi.  In  the  later  stages  of  the 
disease  it  is  wise  to  give  the  patient  night  and  morning  a  glass  of  hot  milk 
containing  a  little  whiskey  or  brandy,  and  follow  this  by  a  dose  of  either  of 
the  above  mixtures.  This  procedure  will  result  in  a  thorough  clearing  out 
of  the  accumulations  of  secretion  in  the   bronchi. 

The  drinking  of  considerable  quantities  of  ordinary  or  of  mineral  water 
will  increase  the  bronchial  secretion  and  render  a  viscid  mucus  easier  of 
expectoration. 

Numerous  expectorant  drugs  in  addition  to  those  above  mentioned  may 
be  used  with  good  effect.  Of  these  perhaps  the  two  most  frequently  employed 
are  ipecac  which  may  be  given  in  powdered  form  or  as  the  wine,  and  ammo- 
nium chloride.  The  following  is  an  excellent  formula:  I^  ammonii  chloridi, 
§ss  (15.0);  extracti  dvcyrrhizas,  5ss  (15.0);  fiuidextracti  eucalypti,  5 i  (30.0); 
syrupi  eriodictyon,  q.s.  ad  §iv  (120.0).  Misce  et  signa  i  teaspoonful  (4.0) 
in  water  every  four  hours.  Hydrocyanic  acid  and  the  balsams  may  be  found 
efiFectual. 

In  preparing  cough  mixtures  the  use  of  s}Tups  should  be  avoided  if  the 
prescription  is  to  be  continued  for  any  long  period,  since  these  are  very  prone 
to  cause  gastric  fermentation. 

When  the  cough  is  distressing  to  the  patient  and  prevents  sleep  relief  may 
be  obtained  by  administering  heroine  in  doses  of  2^4  (0.0027)  of  a  grain,  or 
codeine,  J  of  a  grain  (0.008)  every  four  hours  until  relieved.  It  is  seldom 
necessary  to  use  opium  or  morphine  in  this  connection. 

Inhalations  from  an  inhaler,  of  which  there  are  various  forms,  of  the  vapor 
of  water,  plain  or  to  which  sodium  chloride  (i  to  128),  compound  tincture  of 
benzoin  (i  to  128),  creosote  (i  to  1,500),  fluid  extract  of  belladonna  (i  to  252), 
a  little  turpentine  or  one  of  the  various  tar  preparations  has  been  added 
may  serve  to  loosen  the  bronchial  secretion  and  lessen  the  frequency  of  the 
cough.  These  inhalations  are  especially  useful  in  children  to  whom  they 
may  be  given  from  a  croup  kettle,  the  steam  of  which  is  passed  into  a  tent 
formed  of  blankets  and  arranged  over  the  patient. 

Local  applications  frequently  serve  to  ease  the  pain  in  the  chest,  and  in  the 
opinion  of  some  observers,  certain  forms  of  local  application,  notably  the 
Priessnitz  Umschlag,  which  consists  of  a  compress  of  flannel,  large  enough 
to  envelop  the  entire  chest,  wrung  out  of  water  as  hot  as  the  patient  can 


634  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

endure,  quickly  applied,  covered  with  oiled  silk  and  renewed  when  cold  or 
as  often  as  seems  good  to  the  physician,  have  a  decided  curative  effect.  Cold 
packs,  rubs  and  douches  may  also  be  used. 

Other  applications  which  may  be  mentioned  are  mild  sinapisms,  painting 
with  tincture  of  iodine,  kaolin  poultices,  compresses  spread  with  vaseline  over 
which  a  few  drops  of  turpentine  have  been  sprinkled,  and  various  liniments. 

CHRONIC  BRONCHITIS. 

Synonyms.     Chronic  Catarrh  of  the  Bronchi ;  Chronic  Catarrhal  Bronchitis. 

Definition.  A  chronic  inflammation  of  the  mucous  membrane  hning  the 
bronchi. 

^Etiology.  Chronic  bronchitis  may  rarely  be  a  primary  inflammation, 
but  it  is  more  usually  a  result  of  repeated  attacks  of  acute  bronchitis.  It 
also  is  a  frequent  complication  of  pulmonary  tuberculosis,  pulmonary  emphy- 
sema, chronic  endocarditis  and  nephritis,  and  may  be  due  to  the  continued 
inhalation  of  irritating  substances  such  as  stone  or  coal  dust. 

Pathology.  The  mucous  glands  of  the  bronchi  may  be  hypertrophied; 
the  bronchial  lining  is  coated  with  a  viscid  grayish  secretion  which  contains 
desquamated  epithelial  cells  and  sometimes  blood;  the  walls  of  the  bronchi 
may  be  congested  and  they  may  be  either  thicker  or  thinner  than  normal. 
The  calibre  of  the  bronchi  may  be  increased,  especially  in  old  patients  in 
whom  there  may  be  sacculated  or  fusiform  dilatation  of  the  tubes,  or  it  may 
be  diminished  as  a  result  of  the  increased  secretion.  The  walls  of  the  bronchi 
in  advanced  instances  may  be  ulcerated  or  necrotic. 

Symptoms.  Cough  with  expectoration  is  the  most  characteristic  symptom 
of  this  disease  and  in  milder  instances  it  may  be  the  only  one.  The  cough  is  more 
or  less  troublesome,  depending  upon  the  degree  of  the  inflammation.  It  is 
frequently  most  marked  at  night  and  in  the  morning  and  at  times  may  occur 
in  paroxysms  which  are  relieved  by  the  ridding  the  bronchi  of  a  considerable 
quantity  of  sputum.  The  sputum  may  be  thin  and  mucoid  or  thick  and 
purulent,  in  which  case  it  varies  from  yellow  to  greenish  in  color.  It  con- 
tains pus  cells,  epithelial  cells,  various  kinds  of  bacteria,  mucus  and  at  times 
red  blood  cells  in  varying  number. 

Rise  in  temperature  is  not  a  characteristic  feature  of  this  disease  but  in 
long  standing  instances  in  weakened  individuals  there  may  be  a  slight  febrile 
movement  (ioo°-ioi°  F. — Z1-^°'Z^-Z°  C.)  due  probably  to  absorption  of  septic 
products.  The  lack  of  temperature  elevation  is  a  useful  point  in  the  differen- 
tial diagnosis  from  pulmonary  tuberculosis. 

The  heart  action  in  chronic  bronchitis  is  likely  to  be  uninfluenced  to  any 
great  degree  by  the  disease  itself,  further  than  to  be  slightly  accelerated;  espe- 
cially is  this  apt  to  be  the  case  in  patients  who  exhibit  fever.     The  cardiac 


CHRONIC    BRONCHITIS.  635 

action  is,  however,  usually  affected  by  the  frequently  co-existing  morbid  proc- 
esses in  the  arteries,  kidneys  and  the  heart  itself. 

The  respiration  may  be  more  rapid  than  normal  but  dyspnoea  is  not  a  fea- 
ture of  the  disease  unless  complications  such  as  emphysema  are  present. 

Early  in  the  disease  the  general  condition  is  but  slightly  affected  but  as 
time  goes  on  the  appetite  and  digestion  become  impaired  and  there  is  conse- 
quent loss  of  flesh. 

Fcetid  or  putrid  bronchitis  in  which  the  sputum  has  a  characteristic  foul 
odor  due  to  the  action  of  the  bacteria  of  decomposition,  may  follow  the 
ordinary  type  of  the  disease;  rarely  is  it  primary.  Here  the  characteristic 
odor  of  the  sputum  and  the  fact  that  upon  standing  it  forms  distinct  strata, 
the  upper  thin,  frothy  and  muco-purulent,  the  lower  thicker,  purulent  and 
containing  grayish  bits  of  matter  of  about  the  size  of  a  pea  and  which  the 
microscope  shows  to  consist  of  pus,  fat  crystals,  fungi  and  bacteria  of  various 
sorts,  are  diagnostic  points. 

In  this  form  of  bronchitis  there  is  usually  a  febrile  movement,  at  times  of 
septic  type,  in  which  event  chills  are  often  a  feature.  Putrid  bronchitis  is 
a  severe  variety  of  the  disease  and  during  its  course  metastatic  purulent  proc- 
esses may  be  set  up  in  different  parts  of  the  body. 

Patients  affected  with  chronic  bronchitis  are  usually  better  in  summer  and 
worse  in  winter.  The  disease  is  of  long  course  but  seldom  of  itself  fatal. 
Unfortunately,  however,  the  prognosis  as  to  complete  recovery  is  not  favorable. 
Emphysema  is  a  frequent  co-existent  condition. 

Physical  Signs.  Inspection  may  reveal  little  except  when  there  is  compli- 
cating emphysema,  in  which  case  we  find  the  characteristic  barrel-shaped 
thorax  and  the  diminished  respiratory  excursion.  Upon  palpation  the  hand 
may  detect  the  presence  of  ronchi.  The  percussion  note  may  remain  un- 
changed or  be  hyper-resonant  or  tympanitic  in  emphysematous  patients,  and 
over  a  dilated  tube  containing  excessive  secretion  it  may  be  dull.  In  this 
last  case  free  expectoration  may  result  in  a  return  to  normal  resonance. 
Auscultation  may  reveal  nothing  abnormal  but  usually  the  respiratory  mur- 
mur is  diminished  in  intensity  or  is  harsh  and  numerous  sibilant,  sonorous 
and  moist  rales  are  distinctly  heard. 

Treatment.  The  treatment  of  chronic  bronchitis  is  practically  that  of 
the  prolonged  type  of  acute  bronchitis.  Respiratory  exercises,  thoracic 
massage,  proper  hygiene  and  removal  to  a  high,  dry  inland  climate,  the  tem- 
perature of  which  is  of  slight  importance  and  may  be  left  to  the  choice  of 
the  patient,  during  the  winter  months,  are  strongly  to  be  recommended.  The 
diet  should  be  of  easily  digestible  foods  and  of  good  quantity.  Moderate 
open  air  exercise  and  mild  hydrotherapeutic  procedures  may  be  prescribed 
and  courses  of  treatment  at  watering  places  are  often  attended  with  good 
results. 


636  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

A  point  often  overlooked  is  the  possibility  that  the  bronchitis  may  be  due 
to  or  accentuated  by  lesions  of  the  upper  air  passages;  consequently  these 
should  be  examined  and,  if  necessary,  operative  interference  advised. 

Patients  with  complicating  circulatory  disturbances  or  chronic  nephritis 
are  likely  to  need  cardiac  stimulants  or  vaso-dilators,  together  with  general 
tonics. 

Co-existent  emphysema  should  be  treated  according  to  the  principles  laid 
down  in  the  section  upon  this  subject. 

Of  the  numerous  drugs  employed  in  chronic  bronchitis  perhaps  creosote 
is  the  one  upon  which  the  greatest  dependence  may  be  placed.  Its  greatest 
disadvantage  is  its  tendency  to  disturb  digestion  but  when  properly  admin- 
istered or  given  by  inhalation  this  fault  may  be  avoided.  In  bronchitis,  especi- 
ally of  the  foetid  type,  the  use  of  Robinson's  inhaler  with  the  sponge  moistened 
with  a  mixture  of  equal  parts  of  alcohol,  chloroform  and  beechwood  creosote 
is  often  of  great  benefit.  The  apparatus  should  be  worn  as  continuously 
as  possible  and  after  he  has  become  accustomed  to  it  the  inconvenience  which 
it  causes  the  patient  is  small. 

Creosote  may  be  given  internally,  combined  with  nux  vomica  which  is  an 
expectorant  of  considerable  value,  in  the  following  formula:  I^  Creosoti, 
5 ii  (8.0) ;  tincturae  nucis  vomicae,  oss  (15.0);  tincturae  gentianae  compositae,  q.s. 
ad  oiv  (120.0).    Misce  et  signa  i  teaspoonful  (4.0)  after  each  meal. 

Creosote  carbonate  may  be  substituted  with  advantage  for  creosote.  This 
drug  is  less  disturbing  to  the  stomach  and  less  unpleasant  to  take.  Its  dose 
is  from  10  to  20  minims  (0.66  to  1.33)  three  times  a  day  and  may  be  rapidly 
increased  to  half  an  ounce  (15.0)  per  day. 

The  derivatives  of  turpentine,  terpene  hydrate,  grains  2  to  10  (0.13  to  0.66) 
and  terebene,  minims  3  to  10  (0.2  to  0.66)  are  often  found  useful  as  is  potas- 
sium iodide,  the  last  being  especially  indicated  in  cases  with  scanty  and  tena- 
cious sputum. 

When  a  stimulating  expectorant  is  needed  ammonium  chloride  in  the 
following  combination  may  be  employed:  I^  ammonii  chloridi,  o'^s  (i5-o); 
extracti  glycjTrhizae,  ^ss  (15.0);  fluidextracti  eucalypti,  §i  (30.0);  syrupi  erio- 
dctyon  q.s.  ad  §iv  (120.0).  Misce  et  signa  i  teaspoonful  (4.0)  in  water  every 
four  hours. 

Distressing  cough  may  be  relieved  by  heroine,  grains  2V  (P-°°3)  or  codeine 
grains  j-^  (0.006)  and  the  inhalations  recommended  on  .p.  633  may  be 
found  useful. 

FIBRINOUS  BRONCHITIS. 

Synonym.     Plastic  Bronchitis. 

Definition.  A  rare  variety  of  bronchial  inflammation,  usually  chronic, 
during  the  course  of  which  fibrinous  casts  of  the  bronchial  system  are  formed 


FIBRINOUS    BRONCHITIS.  637 

and  expectorated.  This  affection  has  no  connection  with  croupous  or  diph- 
theritic conditions  in  which  casts  of  the  air  passages  sometimes  occur. 

iEtiology.  This  disease  is  often  associated  with  pulmonary  tuberculosis. 
It  affects  males  more  than  females  and,  while  it  may  occur  at  any  age,  is  some- 
what more  frequent  during  adolescence  and  early  adult  life.  It  is  at  times 
associated  with  other  diseases  but  this  seems  to  be  coincidence  rather  than 
direct  relation. 

Pathology.  Little  is  known  of  the  morbid  anatomy  of  this  condition. 
From  time  to  time  tough,  pulpy,  yellowish-white  material  is  expectorated, 
which,  when  carefully  teased  or  put  into  water  is  seen  to  be  a  hollow  cast  of  a 
bronchial  trunk  and  its  branches.  This  is  composed  of  fibrin  and  leucocytes 
and  may  contain  Charcot-Leyden  crystals  and  Curschmann's  spirals.  The 
bronchi  from  which  the  cast  has  come  have  lost  their  epithelial  lining  and 
there  may  be  congestion  and  infiltration  of  their  submucous  coat. 

Symptoms.  These  resemble  the  symptoms  of  a  marked  bronchitis,  with 
cough  and  dyspnoea,  pain  in  the  side,  and  in  acute  instances,  a  febrile  movement. 
The  sputum  is  scanty  until  the  cast  becomes  loosened  and  is  expelled.  Rarely 
preceding  this  circumstance  blood  may  be  expectorated;  haemoptysis,  usually 
slight,  is  less  infrequent  after  expectoration  of  the  cast.  When  this  last  has 
taken  place  the  symptoms  become  ameliorated  and  recovery  may  ensue. 
More  usually,  however,  the  symptoms  reciu"  after  a  number  of  hours  or  a  few 
days  and  another  cast  is  expectorated,  to  be  followed  at  intervals,  in  certain 
patients,  by  several  more.  When  an  attack  has  terminated  no  recurrence  may 
take  place  or  the  patient  may  experience  a  number  of  subsequent  ones.  The 
disease  is  very  seldom  fatal  although  the  symptoms  of  a  severe  instance  may  be 
alarming. 

The  physical  signs  are  those  of  bronchitis.  As  the  casts  become  loosened, 
over  the  tubes  in  which  they  are  located,  mucous  rales  may  be  audible. 

Treatment.  The  diagnosis  is  seldom  made  before  the  appearance  of  a 
bronchial  cast,  consequently  the  treatment  is  usually  that  of  simple  bron- 
chitis. When  the  diagnosis  is  made,  relief  may  be  experienced  from  the 
inhalation  of  steam,  of  the  vapor  of  lime  water  or  other  alkaline  solution, 
e.g.,  sodium  bicarbonate  5ss  (2.0)  to  the  ounce  (30.0)  of  water,  or  the  use  of 
laryngeal   sprays   of   similar   solutions. 

The  administration  of  mercury  has  been  recommended  and  potassium 
iodide,  especially  in  protracted  instances,  should  have  a  field  of  usefulness. 

Other  drugs  which  have  been  used  in  the  treatment  of  this  condition  are 
atropine,    belladonna,    turpentine,    tar   and   creosote. 

When  the  lesion  is  the  result  of  streptococcus  infection  the  injection  of 
antistreptococcus  serum  is  indicated  but  by  no  m.eans  all  instances  are  due  to 
infection  by  this  organism. 

The  general  treatment,  dietetic,  hygienic,  etc.,  is  identical  with  that  of  ordi- 


638  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

nary  bronchitis;  change  of  cHmate  to  one  where  the  atmosphere  is  dry  and 
bronchial  inflammations  are  rare  will  usually  be  of  benefit. 

SPASMODIC  BRONCHITIS. 

Synonym.     Bronchial  Asthma. 

Definition.  Spasmodic  bronchitis  is  a  paroxysmal  dyspnoea  due  to  a  con- 
traction of  the  muscular  tissue  in  the  walls  of  the  bronchi. 

iEtiology.  Chronic  bronchitis  and  emphysema  are  the  chief  predisposing 
causes  of  this  disease,  but  attacks  of  asthma  may  occur  without  any  apparent 
pulmonary  lesion.  The  predisposition  to  asthma  is  a  feature  in  some  families 
and  here  it  is  probably  the  result  of  a  higlily  organized  and  easily  excitable 
reflex  nervous  system.  Pharyngeal  and  intra-nasal  lesions,  such  as  polypi, 
deflected  septa,  adenoid  vegetations,  etc.,  should  always  be  thought  of  in  con- 
nection with  this  disease. 

Attacks  of  asthma  may  be  excited  by  the  inhalation  of  ordinary  dust, 
irritating  vapors,  the  pollens  or  odors  of  various  plants,  or  of  any  foreign 
substance.  Certain  climates  or  changes  in  the  weather  may  bring  on  parox- 
ysjns,  and  attacks  may  occur  without  any  assignable  cause.  Neurotic  persons 
are  most  likely  to  suffer  from  the  disease  and  it  is  probable  that  the  various 
influences  which  bring  about  asthmatic  attacks  act  in  some  way  upon  a  hyper- 
excitable  reflex  center.  Asthma  may  occur  at  any  age  and  is  more  common 
in  males. 

Pathology.  Asthma  per  se  has  no  pathology.  The  changes  found  in  the 
lungs  of  asthmatic  patients  are  those  regularly  existing  in  chronic  bronchitis 
and  emphysema. 

Symptoms.  Between  the  attacks  the  patient  is  apparently  in  good  health 
unless  there  is  co-existent  pulmonary  disease,  in  which  case  his  symptoms 
are  those  of  the  existing  condition.  The  asthmatic  paroxysm  may  occur 
without  warning — usuaUy  in  the  night — or  there  may  be  prodromal  symptoms 
such  as  a  sensation  of  oppression  about  the  chest,  or  a  feeling  of  restlessness  or 
anxiety.  As  the  attack  comes  on  the  feeling  of  suffocation  increases,  the 
patient  must  sit  up  or  stand  in  order  to  breathe  more  easily  and  the  accessory 
muscles  of  respiration  come  into  play.  The  expression  is  anxious  and  the 
skin  may  be  livid  or  cyanotic.  The  pulse  is  rapid  and  feeble,  but  the  respira- 
tion is  seldom  more  than  slightly  accelerated.  There  is  no  rise  of  tempera- 
ture. The  noise  made  by  the  entrance  and  exit  of  air  into  and  from  the  chest 
may  be  audible  at  some  distance  from  the  patient. 

Such  a  paroxysm  may  last  from  an  hour  or  two  to  several  days,  but  sooner 
or  later  terminates.  It  may  subside  suddenly  or  gradually.  At  times  the 
end  of  an  attack  takes  place  with  a  fit  of  coughing. 

Cough  is  not  a  feature  of  this  disease  and  may  be  entirely  absent  during 


SPASMODIC    BRONCHITIS.  639 

the  attacks,  especially  if  they  be  mild.  The  more  marked  attacks  may  be 
accompanied  by  cough  with  scanty  sputum  of  viscid  muco-pus  containing 
the  typical  Charcot-Leyden  crystals,  Curschmann's  "  spirals  "  and  Laennec's 
'Aperies."     Calcium  oxalate  and  phosphate  crystals  may  also  be  present. 

Asthma  is  a  chronic  but  not  a  fatal  disease.  Certain  patients  tend,  as  they 
grow  older,  to  have  attacks  with  less  frequency  and  in  others  the  opposite  of 
this  statement  is  true.  Cure  may  be  brought  about  in  many  patients  by  a  re- 
moval of  the  cause  of  the  condition  or  by  change  of  climate.  The  condition 
of  the  nose  and  naso-pharynx  of  all  asthmatics  should  be  carefully  examined. 

Physical  Signs.  In  the  intervals  of  the  attacks  the  physical  signs  are 
those  of  the  co-existing  pulmonary  condition.  During  the  paroxysm  they  are 
these  plus  the  typical  signs  of  an  asthmatic  attack  which  are  as  follows:  Inspec- 
tion reveals  rapid  respiration  carried  on  with  much  effort  but  with  little  move- 
ment of  the  thorax;  there  is  retraction  of  the  supra-  and  infra-clavicular, 
and  intercostal  spaces,  as  well  as  of  the  abdomen.  Palpation  reveals  a  ronchal 
fremitus  which  may  obscure  that  of  the  voice.  Percussion  is  normal  unless 
there  is  a  co-existent  emphysema.  Auscultatioti.  Over  both  chests  sonor- 
ous and  sibilant  breathing  so  marked  in  character  as,  at  times,  to  be  per- 
ceptible without  approximating  the  ear  to  the  thorax,  is  heard.  So  typical 
is  this  breathing  that,  once  it  has  been  heard,  no  difficulty  in  recognizing  it 
will  be  experienced.  As  the  attack  subsides  moist  rales  become  audible, 
and  the  sibilant  and  sonorous  sounds  diminish. 

Treatment  consists  in  (a)  the  attempt  to  cut  short  the  attack  and  in  (b) 
the  prevention  of  subsequent  paroxysms.  The  best  means  of  accomplishing 
the  former  object  is  for  the  patient  to  inhale  the  vapor  of  ethyl  iodide.  He 
may  carry  with  him  a  glass-stoppered  vial  containing  a  small  quantity  of  this 
agent,  for  use  when  necessary.  Its  great  disadvantage  is  its  vile  odor  which 
makes  it  very  disagreeable  to  the  patient's  associates.  Ethyl  iodide  in  10 
minim  (0.66)  capsules  taken  every  four  hours  is  also  very  effective  but  causes 
disagreeable  eructations. 

The  inhalation  of  a  few  drops  of  amyl  nitrite  or  of  the  fumes  of  the  various 
so-called  asthma  powders,  which  usually  contain  belladonna  or  stramonium 
leaves  and  potassium  nitrate,  may  afford  relief.  Asthma  powders  must  be 
used  with  care  and  their  fumes  inhaled  only  in  thoroughly  ventilated  places. 
The  following  formula  may  be  found  useful:  I^  stramonii  foliorum,  potassii 
nitratis  aa  §i  (30.0);  beUadonnae  foliorum,  cannabis  indicse  foliorum  aa  §ss 
(15.0).  Misce.  A  tablespoonful  (15.0)  of  this  powder  may  be  burned  upon 
a  dish  and  the  smoke  inhaled.  Cigarettes  made  from  belladonna  or  stramo- 
nium leaves  soaked  in  a  solution  of  saltpetre  and  then  dried  may  be  smoked 
with  good  effect.  Wrapping  these  cigarettes  in  paper  impregnated  with  arsenic 
may  add  to  their  potency.  The  fumes  of  paper  treated  with  saltpetre  when 
inhaled  will  sometimes  cut  short  an  attack. 


640  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Hypnotics  such  as  morphine,  hydrated  chloral  or  hyoscine  hydrobromate 
are  recommended  by  certain  authorities  but  these  should  be  employed  with 
greatest  caution.  They  are  usually  given  hypodermatically  and  in  ordinary 
dosage.  Tincture  of  lobelia — itl  v  to  viii  (0.33  to  0.50)  every  half  hour  until 
two  or  three  doses  have  been  taken — chloralformamide  and  scopolamine 
hydrobromide — gr.  ^^'o  (o-oo°3)  hypodermatically — and  atropine  sulphate 
may  be  employed. 

A  simple  and  sometimes  an  effective  means  of  treatment  during  an  attack 
is  a  hot  foot  bath;  and  in  this  connection  it  is  well  to  mention  the  fact  that 
some  patients  experience  much  relief  from  simple  inhalations  of  steam. 

Heroine  by  some  observers  has  been  found  useful  during  the  paroxysm 
and  may  be  given  hypodermatically  in  doses  of  y  q-  grain  (0.006)  every  hour 
during  the  attack  and  by  mouth  after  the  severity  of  the  paroxysm  is  over. 
It  must  be  remembered  that  this  drug  is  a  morphine  derivative  and  must  be 
cautiously  used.     The  same  may  be  said  of  codeine  in  this  connection. 

Dionine  (morphine  ethyl  chloride)  given  hypodermatically,  gr.  2^  to  ^ 
(0.003  to  0.016)  is  highly  recommended  for  use  during  the  asthmatic  attack. 
It  is  said  to  be  as  efl&cacious  as  morphine  and  is  preferable  to  that  drug  since 
no  habit  is  likely  to  be  induced. 

The  warding  off  of  subsequent  paroxysms  is  to  be  accomplished  by: 

1.  Drug  Medication.  This  consists  principally  of  the  treatment  of  the 
co-existent  chronic  bronchitis  (see  treatment  of  chronic  bronchitis,  p.  635) 
with  certain  additions.  Iodine,  given  in  the  form  of  the  syrup  of  hydriodic 
acid,  oi  (4-o)  in  a  wineglass  (60.0)  of  water  half  an  hour  before  each  meal, 
should  always  be  tried. 

Arsenic  in  the  form  of  arsenic  trioxide — -^^  (0.003)  '^^  ^  grain  after  meals — 
or  Fowler's  solution — 2  to  8  drops  (0.13  to  0.50) — may  act  well  and  the  arsen- 
iated  mineral  waters  may  be  prescribed. 

Sodium  iodide — 5  to  15  grains  (0.33  to  i.oo)  dissolved  in  water — atropine, 
-0^0^  of  a  grain  (0.0003),  ^^^  ^^'^  vomica  in  increasing  doses  are  drugs  which 
may  be  employed  in  the  intervals  of  the  attacks. 

2.  Hydrotherapy.     Douches  and  hot  packs  act  well  upon  some  patients. 
The  latter  are  given  as  follows:     The  patient  is  wrapped  in  a  sheet  wrung 

out  in  as  hot  water  as  he  can  endure,  over  this  is  wrapped  a  blanket,  and  in 
these  the  patient  remains  for  one  hour. 

3.  Hygienic  and  Climatic  Treatment. 

It  is  unnecessary  to  suggest  that  tobacco  and  alcohol  are,  in  most  instances, 
to  be  forbidden  and  that  the  patient  should  lead  a  quiet,  regvdar  life  and  one 
as  far  as  possible  in  accordance  with  hygienic  principles.  The  diet  is  often 
an  important  consideration;  the  digestion  should  be  treated,  if  necessary. 
The  food  should  be  easily  digestible,  nourishing,  and  taken  regularly.  The 
lighter  meats  such  as  fowl,  steak,  chops,  etc.,  and  fish  are  allowable  and  the  green 


BRONCHIECTASIS.  64 1 

vegetables  and  potatoes  may  be  eaten.  Highly  seasoned  dishes,  rich  pastry 
and  fried  foods  are  better  omitted.  It  is  better  that  the  heaviest  meal  come 
in  the  middle  of  the  day,  the  supper  should  be  simple  and  the  patient  should 
retire  on  an  empty  stomach.     Tea  and  coffee  in  moderation  may  be  taken. 

When  all  is  said,  however,  the  physician  will  probably  find  it  necessary  to 
study  the  diet  of  each  patient  separately  and  learn  what  is  and  what  is  not 
well  borne. 

With  regard  to  cHmate  also,  each  patient  is  likely  to  be  found  a  law  unto 
himself  and  it  may  be  necessary  to  do  some  experimentation  before  a  suitable 
resort  can  be  found. 

The  only  hard  and  fast  statement  that  it  is  possible  to  make  is  that  an 
asthmatic  patient  should  reside  where  he  has  the  least  number  of  paroxysms, 
and  it  may  be  found  necessary  to  change  the  residence  with  the  seasons  of 
the  year.  Some  do  wtU  in  the  high  regions  of  Colorado,  others  in  the  warmer 
climates  of  California  or  the  southern  states,  while  the  White  Mountains, 
Lakewood,  or  the  woods  of  the  Adirondacks  or  Maine  will  be  found  to  suit 
still  others. 

When  change  of  climate  is  impossible,  as  is  often  the  case,  the  physician 
will  be  surprised  to  see  how  much  benefit  may  accrue  from  insistence  that 
the  patient  be  in  the  fresh  air  as  much  as  possible  and  that  he  sleep  in  a 
thoroughly  ventilated  room  no  matter  what  the  weather  may  be. 

BRONCHIECTASIS. 

♦ 

Synonym.     Bronchial  Dilatation. 

Definition.     A  dilatation  of  the  bronchial  tubes. 

-Etiology.  Bronchiectasis  is  usually  the  result  of  a  chronic  bronchitis 
which  has  so  weakened  the  walls  of  the  bronchi  that  the  strain  put  upon  them 
in  the  effort  of  coughing  causes  them  to  dilate.  It  is  frequently  found  in 
emphysema  and  may  exist  in  children  as  a  sequela  of  whooping  cough  or 
broncho-pneumonia.  A  bronchiectatic  cavity  may  be  caused  by  the  pressure 
of  bronchial  secretion  retained  behind  an  obstruction  due  to  a  foreign  body 
or  pressure  resulting  from  a  new  growth  or  aneurysm.  Dilatations  of  the 
bronchi  may  also  result  from  the  contraction  of  new  growths  of  fibrous  tissue 
in  the  substance  of  the  lung  or  of  chronic  pleuritic  thickenings.  These  in 
their  contractions  may  so  pull  upon  and  distort  the  bronchi  as  to  produce 
dilatations  or  stenoses.     Congenital  bronchiectases  have  been  described. 

Pathology.  Two  forms  of  bronchiectatic  cavities  may  occur — cylindrical 
and  sacculated,  and  both  may  exist  in  the  same  patient.  Cylindrical  bron- 
chiectases are  more  often  seen  affecting  the  smaller  bronchi,  but  they  may  be 
observed  in  the  larger  tubes. 

The  saccular  bronchiectasis  occurs  as  a  spherical  or  ovoid  enlargement 
41 


642  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

of  a  bronchial  tube.  These  dilatations  are  usually  surrounded  by  compressed 
and  indurated  lung,  the  contraction  of  this  tissue  having  resulted  in  the  bron- 
chiectatic  cavity.  Pleuritic  adhesions  by  their  contraction  may  also  produce 
bronchial  dilatations,  these  usually  being  found  at  the  pulmonary  bases. 
Tuberculous  cavities  oftentimes  have  their  beginnings  in  bronchiectases. 
The  dilated  wall  of  a  bronchiectatic  cavity  is  thinned  and  atrophied,  this  atro- 
phy at  times  affecting  its  mucous  lining,  its  muscular  coat  and  eyen  its  fibrous 
and  cartilaginous  envelope.  The  normal  lining  of  ciliated  epithelium  becomes 
converted  into  pavement  cells.  Ulcerations  of  the  walls  of  the  cavity  which 
may  perforate  into  the  surrounding  pulmonary  tissue  may  occur,  and  there 
may  be  connective  tissue  proliferation  which  takes  the  form  of  projections 
into  the  lumen  of  the  dilatation. 

Symptoms.  The  most  prominent  symptom  is  cough.  This  is  frequently 
most  severe  in  the  morning,  continuing  until  the  bronchiectases  have  gotten 
rid  of  the  accumulated  sputum  of  the  night.  At  first  the  cough  may  be  unpro- 
ductive, then  suddenly,  a  copious  expectoration  taking  place,  it  may  cease 
entirely  until  a  reaccumulation  of  secretion  has  occurred,  when  the  patient 
will  suffer  another  paroxysm.  The  paroxysmal  cough  followed  by  copious 
expectoration  is  characteristic  of  this  condition.  The  sputum  is  usually 
typical.  It  is  often  raised  by  the  mouthful  and  consists  of  a  dull  yellow-green, 
unpleasantly  sweet  smelling  muco-pus.  In  odor  it  is  less  foetid  than  the 
sputum  of  foetid  bronchitis.  On  standing  it  separates  into  three  layers.  Of 
these  the  uppermost  is  of  thin  froth,  the  middle  is  mucoid  and  the  lowermost 
consists  of  purulent  material  with  which  are  mixed  degenerated  epithelial 
cells,  granular  matter,  fatty  acid  and  hasmatoidin  crystals  and  sometimes  red 
blood  cells.  Tubercle  bacilli  may  be  present  if  there  is  co-existent  tuber- 
culous infection. 

A  febrile  movement  is  rarely  present  unless  there  is  complicating  tubercu- 
losis or  pytemic  infection. 

The  course  of  the  disease  depends  upon  the  presence  or  absence  of  the 
above-named  infections  and  upon  the  patient's  general  condition.  While  the 
changes  in  the  lung  are  usually  permanent  they  are  by  no  means  prejudicial 
to  the  continuance  of  life.  A  spontaneous  recovery  has  been  known  to  take 
place  as  a  result  of  an  obliteration  due  to  connective  tissue  growth. 

Physical  Signs.  Small  bronchiectases  may  not  be  demonstrable  during 
life;  larger  ones  when  near  the  surface  present  the  usual  signs  of  a  pulmonary 
cavity.  The  percussion  note  is  flat,  tympanitic  or  cracked  pot;  the  breathing 
may  be  bronchial  or  amphoric;  the  voice  bronchial  or  segophonous.  Pectoril- 
oquy may  be  present.  If  the  cavity  contains  fluid,  gurgling  rales  may  be 
audible.  The  vocal  fremitus  is  often  accentuated  as  a  result  of  the  surround- 
ing pulmonary  induration.  Great  variations  in  physical  signs  are  frequent, 
depending  upon  the  presence  or  absence  of  fluid  within  the  cavity. 


BRONCHIECTASIS.  643 

Treatment.  Proper  hygiene  such  as  that  suggested  in  the  treatment  of 
emphysema  and  chronic  bronchitis  is  absolutely  necessary.  The  patient 
should  avoid  too  damp  and  cold  climates  and  seek  those  of  mild  temperature. 
Air  too  dry,  and  high  altitudes  are  not  likely  to  benefit  the  sufferer.  The 
seaside,  when  not  too  damp,  is  permissible.  The  patient  must  be  warned 
against  exposure  and  should  be  advised  to  wear  woolen  underclothing  the 
year  round. 

Under  proper  precautions,  a  life  in  the  open  air  in  a  proper  climate  is  to  be 
recommended. 

The  expectoration  of  the  accumulations  of  sputum  may  be  facilitated  and 
the  cough  relieved  by  lowering  the  head  of  the  patient.  This  may  be  accom- 
plished by  directing  him  to  stoop  or,  if  he  is.confined  to  bed,  by  raising  the  foot 
of  the  bed  ten  or  twelve  inches. 

With  regard  to  drug  treatment  our  primary  object  must  be  to  maintain  an 
aseptic  condition  of  the  cavities.  The  inhalation  of  vapors  of  creosote  (see 
p.  636)  and  turpentine  may  accomplish  something  toward  this  end.  Eucalyp- 
tus in  either  of  the  following  formulce  may  be  employed:  I^  tincturse  eucalypti, 
Sss  (15.0);  olei  lavandulai,  n\  v  (0.33).  Misce  et  signa — 10  drops  (0.66)  in  a 
pint  (500.0)  of  boiling  water  and  inhale  the  steam.  P^  eucalyptolis,  n-L  Ixxv, 
(5.0);  spiritus  lavandulas,  5v  )2o.o).  Misce  et  signa — 10  to  20  drops  (0.66 
to  1.33)  in  a  pint  (500.0)  of  boiling  water  and  inhale  the  steam.  Inhala- 
tions of  one  to  four  percent,  phenol  and  of  one-half  percent,  solutions  of  thy- 
mol have  been  recommended. 

The  most  satisfactory  inhalation  is  probably  that  of  the  vapor  of  creosote 
and  is  carried  out  as  follows: 

The  patient  is  placed  in  a  small  room  from  which  hangings  and  furniture, 
except  plain  wooden  articles,  have  been  removed-  He  should  be  dressed  in 
a  voluminous  gown  to  prevent  the  odor  of  the  creosote  from  penetrating  his 
clothing,  his  eyes  should  be  protected  by  automobile  goggles  or  an  appliance 
made  of  watch  crystals  and  adhesive  plaster  and  his  nostrils  plugged  with 
cotton.  Creosote  in  a  metal  vessel  is  heated  over  an  alcohol  lamp  or  Bunsen 
burner.  The  vapor  of  the  creosote  will  cause  the  patient  to  cough  and  expec- 
torate profusely.  While  unpleasant  at  first,  this  procedure  soon  becomes 
tolerable  and  the  length  of  the  seance  may  be  increased  from  a  quarter  of  an 
hour  every  two  days  to  an  hour  or  more  every  day.  The  persistent  use  of 
this  treatment  is  said  to  accomplish  excellent  results. 

The  internal  administration  of  medicaments  calculated  to  render  aseptic 
the  bronchial  passages  is  likely  to  be  more  effective  than  are  the  attempts 
to  accomphsh  this  end  by  inhalations.  Creosote,  oil  of  turpentine  in  the  usual 
doses  or  terpene  hydrate,  5  grains  (0.33)  three  times  a  day  may  be  employed. 
Phenol  may  be  given  in  the  following  formula  but  must  be  stopped  if  any 
darkening  of  the  color  of  the  urine  is  observed.     I^  phenolis,  gr.  viiss  (0.5); 


644  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

aquae  destillatae,  5vss  (165.0);  aquae  menthse  piperitae  oiiss  (10. o).  Misce 
et  signa  one  tablespoonful  (15.0)  every  three  hours. 

Myrtol  is  said  to  diminish  the  foetor  of  the  expectoration.  It  may  be  given 
in  capsules  in  doses  up  to  a  drachm  and  a  half  (6.0)  per  day. 

Eucalyptus  in  the  form  of  eucalyptol — 15  to  30  drops  (i.o  to  2.0)  per  day 
in  capsules — or  in  the  following  formula  may  be  prescribed:  I^  tincturae 
eucalypti,  ttl  xlv  (3.00);  aqu^  destillatae,  5vss  (22.0);  syrupi  aurantii,  5iiiss 
(14.0).     Misce  et  signa  one  tablespoonful  (15.0)  every  two  hours. 

Sodium  subsulphate,  one  drachm  (4.0)  daily  in  divided  doses  either  un- 
mixed or  in  combination  with  eucalyptus,  may  be  employed. 

Expectorants  may  be  used  temporarily  when  for  any  reason  it  is  suspected 
that  there  is  retention  of  the  bronchial  secretion.  Of  these  the  most  satis- 
factory are  apomorphine,  ipecac,  and  ammonium  chloride.  Ammonium 
iodide  may  benefit  certain  cases. 

Attempts  to  reach  and  disinfect  the  cavities  by  direct  injections  of  antiseptic 
fluids  have  been  made  but  are  probably  useless  on  account  of  the  impossi- 
bility of  reaching  the  situation  of  the  lesion. 

Hypodermatic  injections  of  guaiacol  or  creosote  in  sterile  olive  oil  have 
been  suggested.  A  half  drachm  (2.0)  of  a  twenty-five  percent,  solution  of 
either  of  these  substances  may  be  given. 

Chopped  garlic — 4  drachms  (15.0)  daily  in  divided  doses — and  oil  of  allyl, 
^  a  minim  (0.03)  are  said  to  favorably  influence  this  disease,  to  better  the 
general  condition  and  to  lessen  the  foetor  of  the  sputum.  Both  these  substances 
are  best  given  in  capsules. 

Intra-tracheal  injections  have  been  strongly  recommended  in  the  treatment 
of  this  condition  but  their  employment,  especially  in  tuberculous  cases,  is 
hardly  to  be  advised.  The  medicament  used  is  generally  some  combination 
such  as  the  following:     Guaiacol  2,  menthol  10,  olive  oil  88. 

The  inhalation  of  oxygen  is  of  little  practical  value. 

Surgical  treatment,  consisting  of  the  opening  of  the  bronchiectatic  cavity 
and  the  evacuation  of  its  contents,  may  be  indicated  if  we  are  certain  of  the 
locality  of  the  lesion,  this  having  been  established  by  preliminary  puncture 
by  an  exploring  needle.  On  the  other  hand  the  many  difficulties  and  dangers 
of  pulmonary  surgery  and  the  fact  that  bronchiectatic  cavities  are  seldom 
single  should  render  us  loath  to  recommend  surgical  intervention  without 
the  most  careful  consideration. 

DISEASES  OF  THE  LUNGS. 
PULMONARY  EMPHYSEMA. 

Emphysema  of  the  lungs  occurs  in  two  principal  forms:  a.  Interlobular 
or  interstitial  emphysema  which  is  the  result  of  rupture  of  the  walls  of  the 


PULMONARY  EMPHYSEMA.  645 

air  cells  and  an  accumulation  of  air  in  the  interlobular  tissues.  This  variety 
may  be  due  to  wounds  of  the  lungs  or  to  any  violent  effort  during  which  a 
considerable  volume  of  air  is  suddenly  introduced  into  the  lungs,  as  in  whooping 
or  other  violent  paroxysmal  cough,  muscular  exertion  in  lifting,  etc.  This 
variety  of  emphysema  is  difficult  of  diagnosis  unless  the  air  released  from  the 
lungs  reaches  in  some  way  the  subcutaneous  tissues  of  the  neck  or  chest.  In 
such  instances  the  existence  of  crepitation  like  that  obtainable  in  surgical  em- 
physema renders  the  condition  capable  of  demonstration. 

b.  Vesicular  emphysema  may  be  subdivided  into  (i)  true  vesicular  emphy- 
sema which  is  a  condition  characterized  by  an  increase  in  the  capacity  of  the 
air  vesicles  followed  by  an  atrophy  of  their  walls,  the  blood-vessels  of  which 
may  be  obliterated;  (2)  compensatory  emphysema  which  results  from  the 
attempt  on  the  part  of  the  organ  or  a  portion  of  it  to  do  the  work  of  a  diseased 
portion  of  the  same  or  the  other  lung;  (3)  senile  or  atrophic  emphysema 
in  which  a  slirinkage  of  the  chest  and  the  lungs  takes  place.  There  is  a  de- 
crease in  the  size  of  the  air  spaces  and  the  condition  is  one  of  senile 
atrophy. 

From  a  clinical  standpoint  only  true  vesicular  emphysema  need  be  dealt 
with. 

.Etiology.  This  disease  is  usually  the  result  of  a  long  standing  chronic 
bronchitis,  which  may  date  back  even  to  childhood.  In  certain  families 
there  seems  to  be  a  hereditary  predisposition  to  the  condition,  and  while  it 
is  essentially  a  disease  of  advanced  life,  it  is  by  no  means  unknown  in  young 
persons  and  even  in  children. 

Persons  subject  to  asthmatic  attacks,  players  upon  wind  instruments, 
glass  blowers  and  those  who  work  in  dusty  or  contaminated  atmospheres 
are  prone  to  the  disease,  and  singing  and  public-speaking  are  also  con- 
sidered predisposing  causes. 

The  statement  that  emphysema  and  pulmonary  tuberculosis  do  not  co-exist 
is  without  foundation. 

Pathology.  The  costal  cartilages  are  usually  ossified  and  the  lungs  of 
greater  than  normal  volume;  elevations  upon  the  surfaces  of  these  organs 
due  to  dilatations  of  the  air  spaces  may  be  visible  to  the  naked  eye.  The 
lungs  do  not  as  a  rule  collapse  upon  removal  from  the  thorax.  Microscopic 
examination  shows  that  the  walls  of  some  of  the  air  spaces  are  thinner  than 
normal,  while  those  of  others  are  increased  in  thickness;  certain  air  spaces 
will  be  found  to  communicate  with  others  by  means  of  openings  in  the  pul- 
monary tissue  dividing  them.  The  connective  tissue  framework  of  the  lungs 
is  hypertrophied,  and  the  appearance  of  the  bronchi  is  that  of  chronic  bron- 
chitis (q.  v.).  In  marked  instances  of  emphysema  there  are,  as  a  rule,  co-existent 
connective  tissue  inflammations  of  other  organs  and  tissues  such  as  the  kidneys, 
liver,  arteries  and  heart   muscle.     There  frequently  is  hypertrophy  of  the 


646  DISEASES    or    THE    RESPIRATORY    SYSTEM. 

right  ventricle  of  the  heart  due  to  the  fact  that  the  pulmonary  inflammation 
has  rendered  greater  force  necessary  to  drive  the  blood  through  the  lungs. 

Symptoms.  The  onset  and  progress  of  the  disease  are  gradual  and  it  may 
exist  for  a  number  of  years  without  causing  noticeable  symptoms.  Usually 
an  increasing  dyspnoea  on  exertion  is  the  first  manifestation  which  attracts  the 
patient's  attention.  This  may  vary  from  a  mere  inconvenience  to  a  distress- 
ing shortness  of  breath.  There  may  be  attacks  of  spasmodic  asthma  due 
either  to  contraction  of  the  bronchial  musculature  or  of  the  arteries. 

There  is  usually  more  or  less  cough  with  muco-purulent  and  sometimes 
blood  stained  sputum.  This  symptom  is  due  to  the  associated  chronic  bronchi- 
tis, is  more  marked  in  the  cold  months  and  may  be  almost  entirely  absent 
in  summer.  Cyanosis  may  occur  as  a  result  of  diminished  aeration  of  the 
blood. 

The  excess  of  work  thrown  upon  the  right  heart  may  result  in  various 
oedematous  conditions,  and  in  certain  patients  the  symptoms  of  the  concomi- 
tant kidney,  cardiac  or  arterial  lesions  entirely  overwhelm  those  of  the  emphy- 
sema and  this  last  escapes  wholly  unnoticed. 

There  is  seldom  a  febrile  movement;  pulse  rate  is,  as  a  rule,  accelerated. 

The  disease  tends  to  progress,  but  its  symptoms  may  be  greatly  relieved  by 
proper  treatment;  it  seldom  results  fatally. 

Physical  Signs.  Inspection.  The  thorax  is  vertically  lengthened  giving 
the  typical  "barrel-shaped"  appearance  to  the  chest.  The  respiratory 
movement  is  slight. 

Palpation.  Vocal  fremitus  is  lessened.  The  cardiac  apex  beat  may  be  dis- 
placed toward  the  right  by  the  pressure  of  the  distended  lung. 

Percussion.  The  note  is  usually  hyper-resonant  in  marked  instances, 
although  it  often  remains  unchanged.  In  quality  it  may  be  either  dull  and 
wooden  or  tympanitic  in  varying  degree.  Cardiac  dulness  is  likely  to  be 
diminished  in  area  and  the  dulness  due  to  the  upper  limit  of  the  liver  may  be 
at  a  lower  level  than  normal. 

Auscultation.  The  vesicular  murmur  is  diminished  in  intensity  and  in 
marked  instances  may  be  inaudible;  expiration  is  prolonged  and  may  be  very 
faint.  Co-existent  bronchitis  may  be  evidenced  by  numerous  rales  of  various 
types.  The  pulmonic  second  sound  is  usually  accentuated  but  may  be  heard 
with  difl&culty,  being  overlaid  by  inflated  lung.  In  cases  with  bronchial 
asthma  there  is  sibilant  and  sonorous  breathing. 

Treatment.  The  co-existing  chronic  bronchitis  or  asthma  should  be 
treated  according  to  the  principles  laid  down  in  the  sections  devoted  to  these 
subjects  (see  pp.  635  and  639).  The  drug  treatment  of  the  disease  itself 
may  not  afford  marked  relief  and  ovu"  chief  dependence  should  be  placed  upon 
hygienic  measures. 

Young   persons   predisposed   through  heredity  to  this  morbid  condition 


PULMONARY  EMPHYSEMA.  647 

should  guard  with  utmost  care  against  any  condition,  mode  of  Hfe  or  occupa- 
tion which  will  make  for  the  disease.  All  attacks  of  bronchitis  should  receive 
careful  treatment  and  the  general  mode  of  life  should  be  in  accordance  with 
the  strictest  hygiene.  Fresh  air,  proper  exercise  and  diet  are  necessities 
and  excessive  employment  of  the  voice,  the  use  of  wind  instruments  and 
occupations  entailing  the  breathing  of  impure  air  are  to  be  studiously  avoided. 

With  regard  to  drug  treatment  we  have  certain  conditions  to  meet,  notably 
the  condition  in  the  lung,  the  constant  dyspnoea,  the  paroxysmal  dyspnoea, 
the  arterial  contraction  and  the  venous  congestion.  We  have  no  drug,  unless 
it  be  iodine,  which  can  influence  the  connective  tissue  changes  in  the 
lung.  It  may  be  given  as  potassium  iodide  or  in  the  form  of  the  syrup  of 
hydriodic  acid  and  may  be  found  to  favorably  influence  the  chronic  dyspnoea 
of  the  disease,  and  the  attacks  of  arterial  contraction.  These  last  may  also 
be  controlled  by  the  administration  of  hydrated  chloral  or  glyceryl  nitrate. 

The  paroxysms  of  dyspnoea,  when  due  to  spasmodic  contraction  of  the 
bronchial  musculature,  are  to  be  treated  similarly  to  ordinary  asthmatic  attacks 
(see  p.  639).  When  they  are  the  result  of  bronchial  congestion  heart  stimu- 
lants, caffeine  sodio-benzoate  gr.  v  (0.33) — digitalis — fluidextract,  rrLi-ii  (0.065 
to  0.13) — convaUeria — fluidextract  rr]^  x-xx  (0.66  to  1.33),  may  be  given.  This 
dyspnoea  may  also  be  relieved  by  drugs  which  increase  the  secretion  of 
bronchial  mucus,  such  as  apomorphine  hydrochloride  gr  -^  (0.002),  and 
dry  cupping  may  be  fuond  useful  in  this  connection. 

Contraction  of  the  arteries  causing  spasmodic  dyspnoea  may  be  treated 
by  arterial  dilators  such  as  glyceryl  nitrate,  gr.  y^-g- to --^  (0.0006  to  0.0012), 
hydrated  chloral,  gr.  v  to  x  (0.33  to  0.66)  or  inhalations  of  amyl  nitrite. 

Most  observers  at  present  consider  the  exhibition  of  expectorants  in  simple 
emphysema  as  useless. 

The  emphysema  mixture  which  is  found  in  most  hospital  and  dispensary 
formularies  may  be  found  useful  in  certain  patients,  combining  an  expectorant 
with  two  antispasmodics  and  potassium  iodide.  The  following  formula  is 
one  in  common  use:  I^  potassii  iodidi,  5ii  (8.0);  tincturae  belladonnse,  '^'m 
(12.0);  spiritus  aetheris  compositi,  oi  (30.0);  fluidextracti  pruni  virginianae 
5ii  (8.0);  syrupi,  5vi  (24.0);  aquae  destillatae  q.s.  ad  §iv  (120.0).  Dose  i 
teaspoonful  (4.0),  every  four  hours. 

Thoracic  pain  may  be  lessened  by  mild  poultices  of  mustard  or  flaxseed, 
or  by  the  application  of  squares  of  flannel  wrung  out  in  water  as  hot  as  can 
be  endured,  applied  to  the  chest  and  covered  with  oiled  silk;  in  this  connec- 
tion certain  liniments,  e.g.,  equal  parts  of  menthol,  hydrated  chloral  and 
camphor,  well  rubbed  together,  or  an  ointment  of  salicylic  acid  in  lanolin  1 
to  8  may  be  useful. 

Hygienic  treatment  consists  first  in  the  institution  of  respiratory  gymnas- 
tics and  massage  (which  to  a  certain  extent  limber  the  ossified  costal  cartilages 


648  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

and  render  the  expansion  and  contraction  of  the  thorax  more  like  that  of 
the  normal  chest)  combined  with  general  gymnastics.  By  these  means  much 
toward  restoring  the  normal  elasticity  to  the  distended  pulmonary  alveoli 
may  be  accomplished.  Pulmonary  gymnastics  have  as  their  basis  deep  inspir- 
ation and  expiration  and  the  bringing  into  play  as  much  as  possible  the  access- 
ory muscles  of  respiration.  During  the  process  the  mouth  should  remain 
shut  and  the  chest  and  abdomen  must  be  free  from  the  slightest  constriction 
by  clothing.  The  patient  should  remember  that  moving  the  arms  from  the 
chest  aids  inspiration  and  moving  them  toward  the  chest  aids  expiration.  The 
simplest  form  of  the  gymnastics  consists  in  raising  the  arms  from  the  sides 
to  the  horizontal;  during  this  motion  the  wrists  are  being  supinated  so  that 
at  its  completion  the  palms  shall  be  upward,  and  a  deep  inspiration  is  being 
taken.  The  movements  are  now  carried  out  reversed  in  order  and  as  the 
hands  reach  the  sides  the  patient  squats,  bending  hips  and  knees  until  the 
hands  touch  the  floor.  During  the  reversal  of  the  exercise  the  patient  should 
expire.  These  movements  may  be  undertaken  either  with  or  without  a  light 
wooden  dumbbell  in  either  hand.  Wlien  first  undertaking  this  procedure 
the  patient  must  be  cautioned  to  rest  after  the  completion  of  each  series  of 
movements  and,  even  when  accustomed  to  the  exercise,  five  or  six  inspirations 
at  a  time  will  be  found  sufiicient  for  most  individuals;  in  certain  patients  it 
may  be  found  advisable  to  omit  the  leg  movements  entirely.  The  amount 
of  such  exercise  to  be  taken  should  be  definitely  laid  down  by  the  physician 
and  he  should  personally  instruct  the  patient  in  the  carrying  out  of  the 
movements. 

Certain  other  forms  of  movements  have  been  recommended  for  use  in 
emphysema  but  those  described  above  will  be  found  efficacious  and  sufficient. 

The  use  of  the  pneumatic  cabinet  is  attended  by  good  results  but  treat- 
ment by  this  means  is  expensive,  inconvenient  and  in  no  way  superior  to 
that  by  means  of  respiratory  exercises.  The  cabinet  is  so  arranged  that  the 
patient  undergoing  treatment  breathes  air  at  a  gradually  increasing  pressure 
for  thirty  minutes,  then  when  the  pressure  has  been  augmented  from  50  to 
100  percent,  it  is  kept  stationary  for  from  thirty  to  sixty  minutes;  during  the 
last  half  hour  of  the  seance  the  pressure  is  allowed  gradually  to  fall  to 
normal,  too  rapid  reduction  of  the  pressure  being  likely  to  have  a  bad  effect  on 
the  patient.  The  good  results  accruing  in  many  instances  from  this  form  cf 
treatment  are  distinct  but  hard  to  account  for.  Lazarus,  who  has  had 
much  experience  with  this  procedure,  considers  it  absolutely  contra-indicated 
in  patients  with  calcified  costal  cartilages,  rigidity  of  the  chest  and  arterial 
degeneration. 

Waldenburg's  apparatus  is  based  on  the  theory  that  if  compressed  air  can 
be  inspired  the  blood  will  be  more  thoroughly  aerated  and  that  if  the  patient 
expires  into  rarefied  air  the  residual  air  will  be  withdrawm  from  the  lungs. 


PULMONARY  EMPHYSEMA.  649 

The  apparatus  is  complicated  and  costly  and  the  results  obtained  from  its 
use  are  more  probably  due  to  the  respiratory  gymnastics  attendant  upon 
its  employment  than  anything  else. 

The  appliance  described  by  Striimpell  consisting  of  two  boards  fastened 
together  behind  and  applied  one  to  each  side  of  the  chest  is  ingenious  and 
simple.  The  patient,  by  grasping  the  projecting  ends  of  the  board  in  front 
and  bringing  them  together,  can  considerably  increase  his  respiratory  power. 

Compression  of  the  thorax  by  means  of  corsets,  belts  and  girdles  of  various 
patterns  has  been  advocated  but  with  regard  to  these  and  all  other  apparatus 
it  may  be  said  that  respiratory  gymnastics  properly  carried  out  are  much 
simpler  and  afford  quite  as  good,  if  not  better,  results. 

Oxygen  inhalations  may  be  advised  when  the  patient  is  suffering  from 
extreme  dyspnoea  and  cyanosis.  They  encourage  the  patient  and  relieve, 
temporarily  at  least,  these  distressing  symptoms.  When  used  as  a  routine 
they  may  affect  favorably  the  heart's  action  and  possibly  benefit  the  lungs. 

Massage  with  the  hand  or  with  the  vibrator  is  an  excellent  method  of  ren- 
dering more  flexible  the  ossified  costal  cartilages  and  diflScultly  movable 
ribs  of  the  emphysematous  thorax,  and  in  addition  it  may  have  a  favorable 
action  upon  a  sluggish  circulation.  When  massage  is  used  in  connection  with 
warm  douching,  the  temperature  of  the  water  should  be  about  100°  F.  (37.8° 
C.)  and  it  should  be  applied  in  a  single  jet  under  pressure  for  from  six  to 
ten  minutes.  The  massage  produced  by  the  jet  of  water  increases  the  con- 
tractile power  of  the  respiratory  muscles  and  thus  renders  the  inspiratory 
effort  deeper  and  more  easy.  Experimentation  has  shown  that  after  douching 
the  lung  capacity  is  increased  and  that  the  vesicular  murmur,  scarcely  audible 
before,  may  be  distinctly  heard.  Compression  of  the  chest  by  the  hands  of 
the  masseur  during  the  douche  and  movements  to  aid  in  expansion  and  con- 
traction of  the  thorax  should  increase  the  good  effect,  and  the  venous  conges- 
tion,at  the  same  time  may  be  lessened  by  the  application  of  stroking  move- 
ments away  from  the  heart,  along  the  body  and  limbs. 

Climate  in  the  treatment  of  emphysema  is  an  important  consideration  for 
those  whose  circumstances  render  travel  a  possibility.  With  regard  to  the 
choice  of  a  climate  it  may  be  said  that  in  general  the  warm  dry  regions  are 
preferable  to  those  where  the  opposite  of  these  conditions  obtains.  Some 
patients  will,  however,  be  found  to  thrive  in  warm  moist  regions  and  fre- 
quently a  change  from  a  warm  dry  climate  to  a  warm  moist  one  and  vice 
versa  will  cause  benefit.  It  is  unnecessary  to  state  that  the  air  should  be 
pure  and  free  from  contamination  from  dust  or  other  substances.  Moderate 
pedestrian  exercise  and,  in  patients  in  whom  the  heart  is  unaffected,  hill 
climbing  may  benefit  the  patient. 

The  patient  should  be  instructed  not  to  dress  so  warmly  as  to  interfere 
with  his  health  and  yet  his  clothing  should  be  of  sufficient  warmth  to  prevent 


650  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

catching  cold,  particularly  if  he  be  well  along  in  years.  Younger  patients 
should  take  care  to  harden  themselves  so  that  they  may  be  proof  against 
sudden  changes  in  the  weather.  The  daily  cool  bath  may  be  recommended 
to  such  as  obtain  a  proper  reaction  after  being  subjected  to  it. 

The  diet  should  be  plain,  nourishing  and  easily  digestible.  Over-eating 
-must  be  carefiilly  avoided.  The  ingested  fluids  should  be  of  moderate  quan- 
tity and,  while  tea  and  coffee  may  be  allowed  in  proper  amounts,  alcohol, 
except  in  old  patients  where  it  is  needed  as  a  stimulant,  is  to  be  forbidden. 
Abdominal  distention  must  be  guarded  against  and  the  bowels  should  be  kept 
regularly  open. 

While  it  is  doubtful  if  any  of  the  mineral  waters  affects  the  disease  in  any 
way  it  is  quite  certain  that  life  at  the  various  spas,  when  the  climatic  condi- 
tions are  proper,  benefits  many  patients,  probably  because  of  the  regulation 
of  diet,  exercise  and  mode  of  life  prescribed  at  these  resorts. 

SYPHILIS  OF  THE  LUNGS. 

Synonyms.     Pulmonary  Syphilis;  Syphilitic  Pneumonia;  Syphilitic  Phthisis. 

.Etiology.  Syphilitic  inflammations  of  the  lungs  may  be  either  congenital 
or  acquired;  pulmonary  syphilis  in  the  new  born  is  not  very  rare  but  the  ac- 
quired inflammation  in  the  adult  is  uncommon. 

Pathology.  Hereditary  syphilis  of  the  lung  in  the  new  born  manifests 
itself  as  gummata  scattered  through  the  organ  or  as  a  consolidation  of  the 
lung  tissue  which  is  whitish  in  color  and  in  which  the  alveoli  are  filled  with 
an  over-growth  of  epithelium  which  is  sometimes  fatty. 

In  adults  syphilitic  inflammation  of  the  lung  is  characterized  by  the  forma- 
tion of  gummata  or  of  new  connective  tissue.  From  the  growth  of  new  tissue 
consolidation,  constriction  of  blood-vessels  or  bronchi,  and  pleural  thicken- 
ings may  result.  The  new  tissue  is  likely  to  break  down  and  result  in  necro- 
sis and  ulceration. 

Symptoms.  In  infants  these  are  not  diagnostic  except  in  so  far  as  they 
accompany  specific  manifestations  in  other  organs.  The  patient  loses  weight 
and  strength  and  presents  the  physical  signs  of  pulmonary  consolidation. 
The  prognosis  is  distinctly  bad. 

In  adults  syphilis  of  the  lung  is  usually  a  late  tertiary  lesion.  The  diagnosis 
is  not  easy  but  may  be  simplified  by  the  history  and  the  existence  of  other 
stigmata  of  specific  disease.  Cough  may  be  present,  with  muco-purulent 
expectoration  and  occasional  and  usually  small  hasmoptyses,  but  is  not  a 
prominent  symptom.  There  is,  as  a  rule,  progressively  increasing  dyspnoea, 
at  first  this  is  present  only  on  exertion  but  later  it  becomes  very  urgent  and  is 
constant.  There  may  be  a  moderate  degree  of  fever  but  this  is  more  com- 
monly absent;  thoracic  pain  is  an  inconstant  symptom. 


NEOPLASMS    OF    THE    LUNGS.  65 1 

The  condition  is  a  chronic  and  progressive  one  lasting  for  months  with 
gradually  increasing  weakness  and  emaciation. 

The  physical  signs  offer  little  help  in  diagnosis.  They  are  most  prominent 
over  the  roots  of  the  lungs  in  contradistinction  to  those  of  pulmonary  tuber- 
culosis which  are  more  likely  to  be  at  the  apices,  and  depend  upon  the  ana- 
tomical condition  of  the  organ. 

The  co-existence  of  syphilis  and  tuberculosis  of  the  lung  has  been  observed. 

Treatment.  As  soon  as  the  syphilitic  origin  of  the  condition  is  suspected 
the  patient  should  be  put  upon  a  vigorous  antisyphilitic  treatment,  and  under 
favorable  conditions,  a  cure  should  be  perfectly  possible.  Inunctions  of  mer- 
cury should  be  prescribed;  about  half  a  drachm  (2.0)  of  unguentum  hydrargyri 
should  be  thoroughly  rubbed  into  the  skin,  a  different  part  being  chosen  each 
day  for  six  days  and  the  underclothing  should  not  be  changed  until  the  end  of 
this  period  when  the  patient  is  allowed  to  take  a  bath.  This  routine  is  con- 
tinued for  six  weeks  and  for  the  latter  half  of  the  period  the  dosage  of  the  mer- 
cury is  increased  by  one-half.  Salivation  should  be  guarded  against  by  the 
daily  use  of  a  mouth  wash  of  potassium  chlorate,  two  to  four  percent,  solu- 
tion. 

The  use  of  the  iodides  is  said  to  be  less  satisfactory  than  that  of  mercury; 
they  may,  however,  be  employed.  Their  dosage  should  be  regulated  by  the 
results  obtained.  Either  potassium  or  sodium  iodide  or  the  syrup  of  hydriodic 
acid  may  be  employed.     (See  the  section  upon  the  treatment  of  syphilis  ) 

Most  authorities  consider  that  concurrent  pulmonary  tuberculosis  is  not 
a  contra-indication  to  the  use  of  antisyphilitic  remedies. 

NEOPLASMS  OF  THE  LUNGS. 

.Etiology.  New  growths  of  the  lungs  are  either  primary  or  secondary. 
They  may  be  of  carcinomatous,  sarcomatous  or  lymphomatous  type.  Of 
these  the  first  may  occur  either  as  a  primary  or  a  secondary  tumor  while 
the  two  latter  occur  secondarily  only. 

Pathology.  Primary  carcinomata  of  the  lung  usually  begin  in  the  walls 
of  the  small  bronchi.  Both  the  primary  and  secondary  carcinomata  progres- 
sively increase  in  size  and  either  compress  the  bronchi  or  are  associated  with 
exudative  or  productive  inflammation  in  such  a  manner  that  they  result  in 
consolidation  of  portions  of  the  lung  of  greater  or  less  size,  or  suppuration 
may  take  place  with  the  formation  of  abscesses.  The  pleura  may  be  secon- 
darily involved. 

Pulmonary  sarcomata  are  secondary  to  primary  growths  of  other  parts. 
They  usually  occur  as  scattered  nodules  or  as  larger  tumors  which  compress 
the  bronchi.     Secondary  involvement  of  the  pleiira  may  take  place. 


652  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Lymphomatous  tumors  have  their  inception  in  the  bronchial  glands  and 
develop  from  the  root  of  the  lung  along  the  course  of  the  bronchi  or  of  the 
septa  between  the  lobes  of  the  lungs. 

Physical  Signs.  These  are  due  to  the  compression  of  the  bronchial  tubes, 
in  which  case  we  obtain  tubular,  diminished  or  absent  breathing  over  the 
affected  tubes;  to  the  areas  of  pulmonary  consolidation,  in  which  the  usual 
signs  of  localized  consolidation  are  present;  to  the  presence  of  fluid  in  the 
pleural  cavities,  where  the  typical  signs  of  pleuritic  effusion  are  obtainable. 

Symptoms.  The  most  prominent  symptom  is  slowly  increasing  dyspnoea. 
At  first  it  may  be  slight  and  present  upon  exertion  only,  later  it  is  continuous 
and  severe.  It  is  due  to  the  pressure  of  the  growth  upon  the  bronchi.  There 
may  be  cough  with  muco-purulent  expectoration  which  at  times  is  blood- 
stained, a  slight  febrile  movement  and  thoracic  pain.  There  is  progressive 
loss  of  flesh  and  strength  with  the  gradual  appearance  of  the  typical  cancerous 
cachexia.  If  there  is  history  of  a  previous  new  growth  of  some  other  part  the 
diagnosis  is  simplified,  otherwise  it  is  difficult  unless  the  sputum  contains 
bits  of  tissue,  which,  upon  microscopical  examination,  prove  to  be  cancerous 
in  origin. 

Treatment.  This  consists  in  rendering  the  patient  as  comfortable  as  pos- 
sible and  meeting  indications  as  they  rise.  (See  treatment  of  new  growths 
of  the  pleura,  p.  670). 


HYDATID  DISEASE  OF  THE  LUNGS. 

This  is  an  infrequent  condition  and  is  difficult  of  diagnosis  unless  fragments 
of  cyst  wall  or  booklets  are  demonstrated  in  the  sputum.  The  symptoms 
and  physical  signs  resemble  those  of  other  pulmonary  growths. 

Treatment.  According  to  most  observers  patients  with  this  affection  do 
better  if  operative  intervention  is  undertaken.  This  consists  of  either  aspira- 
tion of  the  cysts  and  withdrawal  of  their  contents,  or  preferably  pneumot- 
omy.  The  latter  procedure  consists  in  cutting  into  the  cyst,  evacuating  its 
contents  and  if  possible  removing  the  cyst  wall. 

ABSCESS  OF  THE  LUNG. 

Synonym.     Pulmonary  Abscess. 

.Etiology.  The  cause  of  abscess  in  the  lung  is  infection  by  one  or  more 
of  the  varieties  of  pus-forming  micro-organisms.  Pulmonary  abscess  may 
result  from  traumatism,  from  the  lodgment  in  the  lung  of  septic  emboli  from 
other  parts  of  the  body,  or  from  foreign  bodies.     It  may  be  secondary  to  other 


ABSCESS    OF    THE    LUNG.  653 

pulmonary  inflammations  such  as  broncho-  or  infectious  pneumonia  or  it 
may  result  from  the  bursting  of  abscesses  in  other  parts,  hepatic,  subdiaph- 
ragmatic, mediastinal,  pleural,  etc.,  into  the  lung.  It  is  quite  possible  for 
extraneous  collections  of  pus  to  be  discharged  into  the  lung  and  to  be  expec- 
torated without  the  formation  of  a  true  pulmonary  abscess. 

•  Pathology.  Abscess  of  the  lung  is  usually  multiple;  when  single  it  is  usually 
a  sequela  of  pneumonia,  the  result  of  a  wound  or  the  lodgment  of  a  foreign 
body.  Pulmonary  abscess  exists  as  a  diffuse  suppurative  process  without 
limitation  by  an  abscess  wall  or  as  a  discrete  collection  of  pus  shut  off  from 
the  surrounding  tissue;  such  abscesses  may  result  in  recovery  with  the  for- 
mation of  fibrous  tissue  which,  by  its  contraction,  finally  closes  what  was  for- 
merly the  abscess  cavity. 

Abscess  may  result  from  the  infection  of  a  hydatid  cyst  of  the  lung. 

Symptoms.  In  the  early  stages  pulmonary  abscess  may  give  no  distinctive 
symptoms,  the  patient  complaining  of  nothing  more  than  cough  with  little 
or  no  expectoration,  and  an  irregular  febrile  movement.  As  the  disease  pro- 
gresses the  temperature  becomes  more  distinctly  septic  in  type  and  there  may 
be  sweats  and  chills.  There  is  usually  a  marked  leucocytosis  (25,000  to  40,000 
or  more)  and  the  sputum  may  become  increased,  purulent  and  may  contain 
shreds  of  connective  tissue.  Pyogenic  bacteria  may  be  demonstrable  but  no 
tubercle  bacilli  are  present.  The  sudden  ruptiu-e  of  a  large  abscess  cavity 
is  evidenced  by  the  expectoration  of  a  considerable  amount  of  pus  and  such 
a  circumstance  is  strongly  suggestive  of  the  presence  of  this  lesion.  After 
rupture  such  an  abscess  may  proceed  to  heal  and  perfect  recovery  may  fol- 
low. Less  favorable  instances  continue  expectorating  pus  from  time  to  time, 
gradually  becoming  weaker  as  a  result  of  the  toxaemia  due  to  septic  absorp- 
tion, until  death  takes  place  from  this  or  from  loss  of  blood  consequent  upon 
the  erosion  of  a  vessel. 

Physical  Signs.  Small  multiple  abscess  rarely  gives  physical  signs.  Abscess 
following  pneumonia  presents  the  signs  of  the  primary  condition.  In  a  word 
the  diagnosis  of  pulmonary  abscess  by  physical  examination  alone  is  all  but 
impossible. 

Treatment.  The  patient's  strength  should  be  sustained  by  plenty  of 
nourishing  and  easily  digestible  food.  Exposure  should  be  avoided  but  life 
in  the  open  air  in  a  proper  climate  is  of  great  benefit.  Drug  treatment  with 
a  view  to  the  production  of  antisepsis  of  the  bronchial  tract  by  means  of  inha- 
lations and  internal  medication  as  described  under  the  treatment  of  bronchiec- 
tasis is  indicated. 

Tonics  such  as  iron  and  codliver  oil,  and  stimulants  such  as  alcohol  and 
strychnine,  will  be  found  useful. 

Sedatives  to  relieve  the  distressing  cough  may  be  employed.  Of  these 
heroine  and  codeine,  with  morphine  as  a  last  resort,  are  the  best. 


654  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Surgical  measures  may  be  employed  when  the  location  of  the  abscess  can 
be  distinctly  fixed  and  when,  despite  medical  treatment,  there  is  no  tendency 
to  recovery.  The  abscess  should  be  localized  with  an  aspirating  needle 
and  when  the  pus  is  found  the  instrument  should  be  left  in  situ  in  order 
that  the  seat  of  the  process  may  be  easily  found  during  the  operation;  then 
under  chloroform  anassthesia  the  thoracic  waU  and  pleura — the  latter  being 
sutured  as  soon  as  divided  to  prevent  the  entrance  of  air — are  incised,  pneu- 
motomy  is  performed,  the  abscess  cavity  is  opened,  drained,  without  irriga- 
tion, and  dressed. 

GANGRENE  OF  THE  LUNG. 


Synonym.     Pulmonary   Gangrene. 

Definition.     Death  of  pulmonary  tissue  with  putrefaction. 

.Etiology.  For  the  production  of  pulmonary  gangrene  impairment  of  the 
vitality  of  a  portion  of  the  lung  and  infection  with  the  micro-organisms  of 
putrefaction  are  necessary.  The  most  common  causes  which  bring  about 
these  results  are  infectious  pneumonia,  pulmonary  infarcts,  embolism  of  the 
pulmonary  or  bronchial  blood-vessels,  injuries  to  the  lungs,  the  presence  of 
foreign  bodies  and  the  extension  of  infections  from  the  mediastinum,  oesophagus, 
thoracic  wall,  ribs,  vertebral  column  or  the  abdominal  cavity.  The  pressure 
of  new  growths  and  aneurysms  may  interfere  with  the  pulmonary  blood  sup- 
ply to  such  an  extent  as  to  cause  gangrene.  Lastly,  instances  may  occur 
without  assignable  cause.     Adult  males  are  most  often  affected. 

Pathology.  The  gangrenous  process  may  affect  a  greater  or  less  portion 
of  the  lung  tissue.  It  may  be  single  or  occur  as  multiple  foci,  soft,  dark  greenish 
in  color  and  of  most  foetid  odor;  the  foci  may  become  cavities  with  foul  contents 
and  ragged  walls.  The  surrounding  pulmonary  tissue  is  the  seat  of  an  inflam- 
mation with  the  exudation  of  fibrin  and  pus.  The  neighboring  blood-vessels 
may  become  plugged  with  infectious  thrombi  from  which  emboli  may  be 
separated  and  carried  to  various  parts  of  the  body,  or  erosion  of  these  vessels 
followed  by  haemorrhage  may  take  place.  If  the  focus  is  near  the  pleura  there 
may  be  a  complicating  empyema  or  pyopneumothorax.  There  is  usually 
a  bronchitis  due  to  the  passage  of  the  gangrenous  exudate  through  these 
tubes.  Gangrenous  foci  may  heal  leaving  behind  cavities  with  walls  of  con- 
nective tissue.  The  process  usually  affects  a  portion  of  one  of  the  lower 
lobes  but  it  may  involve  an  entire  lung. 

Symptoms.  Early  in  the  disease  these  may  be  indefinite  but  the  patient 
exhibits  prostration,  rapid  and  feeble  heart  action  and  respiration,  and  an 
irregular  febrile  movement.  Cough  is  present  but  the  sputum  is  neither 
abundant  nor  characteristic  until  the  gangrenous  foci  break  down.     When 


GANGRENE    OF    THE    LUNG.  655 

this  has  taken  place  the  breath  becomes  very  foul  and  the  sputum  extremely 
foetid.  On  standing  it  separates  into  three  strata,  the  uppermost  frothy,  opaque 
and  dirty-yellow  or  grayish,  the  middle  thin  and  mucoid  and  the  lowermost 
green  or  brownish  and  containing  shreds  of  dead  lung,  pus,  red  blood  cells, 
bacteria,  and  crystals  of  the  fatty  acids  and  of  leucin  and  tyrosin.  Consider- 
able haemoptyses  may  occur  due  to  the  erosion  of  blood-vessels  by  the  gan- 
grenous process. 

As  the  disease  goes  on  the  condition  of  the  patient  may  become  septic, 
loss  of  flesh  and  strength  is  progressive,  and  suppurative  processes  in  other 
parts  of  the  body  may  be  set  up  by  the  lodgment  of  septic  emboli. 

Physical  Signs.  In  small  areas  of  gangrene  these  may  not  be  well-marked 
but  over  large  foci  the  percussion  note  is  dull  or  flat,  the  breathing  is  absent 
(Behier-Hardy's  sign)  or  bronchial,  the  voice  increased  or  bronchial.  There 
may  be  coarse,  moist  or  subcrepitant  rales.  If  the  pleura  is  involved  the 
physical  signs  of  effusion  or  pyopneumothorax  are  obtainable. 

The  prognosis  of  this  condition  is  distinctly  not  good  but  recovery  may  take 
place.  Instances  complicated  by  empyema  are  said  to  be  more  likely  to  re- 
cover than  those  not  so  affected. 

Treatment  consists  in  keeping  up  the  patient's  strength  by  proper  food, 
stimulation  by  means  of  strychnine  and  alcohol,  and  the  administration  of 
medicaments  with  a  view  toward  neutralizing  the  septic  process.  Inhala- 
tions, such  as  those  described  under  the  treatment  of  bronchiectasis,  (p.  643) 
are  indicated.  Phenol  solution,  4  percent.,  may  be  administered  in  this  manner 
by  means  of  an  atomizer  or  the  drug  may  be  administered  internally — a 
half  ounce  (15.0)  of  a  one-half  percent,  solution  flavored  with  peppermint 
water,  three  times  a  day.  Hasmoptyses  may  be  controlled  by  the  adminis- 
tration of  plumbi  acetas  gr.  i  (0.065),  sacchari  q.s.  ad  gr.  x  (0.66),  one  powder 
three  times  or  more  daily,  or  by  means  of  calcium  lactate  20  grains  (1.33) 
three  times  a  day. 

The  cough  may  be  relieved  by  heroine  or  codeine  in  the  usual  doses  and 
when  these  fail,  recourse  may  be  had  to  morphine. 

The  use  of  quinine  in  moderate  doses  is  recommended  on  account  of  its 
antipyretic  action  and  it  is  said  to  possess  antiseptic  properties  as  well. 

Operative  treatment  may  be  considered  when  the  septic  process  continues 
despite  other  treatment  and  when  the  patient  is  manifestly  doing  ill.  It  is 
particularly  indicated  when  there  is  pleural  involvement  or  when  the  gan- 
grenous focus  can  be  demonstrated  to  be  near  the  chest  wall.  The  fact  that 
instances  complicated  by  empyema  are  likely  to  do  well  should  be  an  argu- 
ment in  favor  of  surgical  treatment  even  when  the  pleura  is  not  involved. 
The  technique  is  the  same  as  that  of  the  operation  for  pulmonary  abscess 
(p.  654)  and  it  is  important  that  the  anaesthesia  should  be  as  short  as 
possible. 


656  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

DISEASES  OF  THE  PLEURA. 
ACUTE  FIBRINOUS  PLEURISY. 

Synonyms.  Pleurisy  with  the  Effusion  of  Fibrin;  Fibrinous  Pleurisy;  Dry 
Pleuritis. 

Definition.  An  acute  inflammation  of  the  pleura  resulting  in  the  produc- 
tion of  fibrin  upon  its  surface. 

.(Etiology.  Dry  pleurisy  may  result  primarily  from  exposure  to  the  inclem- 
encies of  the  weather;  it  may  be  secondary  to  injuries  of  the  chest  walls  such 
as  fractures  of  the  ribs,  to  inflammations  of  the  lungs,  to  the  infectious  diseases, 
especially  influenza,  and  to  chronic  nephritis.  The  causative  factor  of  rheu- 
matic inflammations  having  a  predisposition  to  attack  the  serous  membranes 
makes  the  supposition  probable  that  there  is  a  rheumatic  element  in  many 
instances  of  this  condition. 

Pathology.  The  inflammation  begins  upon  the  pulmonary  or  the  costal 
pleura  depending  upon  the  causative  factor  and  extends  to  the  opposite 
pleural  surface.  As  a  rule  there  is  only  a  limited  area  of  the  pleura  involved; 
rarely  the  entire  pleura  of  one  side  may  be  affected.  The  inflamed  surfaces 
are  coated  with  an  exudation  of  strands  of  fibrin  which  forms  adhesions  between 
them  and  in  the  meshes  of  which  there  is  an  exudation  of  a  gelatinous j  fluid 
which  tends  to  become  organized,  causing  persistent  adhesions  between  the 
pleural  surfaces. 

As  the  inflammation  subsides  the  exuded  fibrin  tends  to  become  absorbed 
but  the  pleura  usually  remains  thickened  and  often  permanent  adhesions 
remain. 

Symptoms.  In  the  less  severe  instances  the  only  symptom  may  be  a  severe 
knife-like  pain  in  the  chest  which  is  especially  marked  upon  deep  inspiration 
or  upon  movements  of  the  thorax  or  arms.  Patients  affected  with  more 
extensive  inflammation  of  the  pleura  exhibit  a  moderate  fever,  general  pains, 
prostration,  a  cough  without  expectoration  and  a  lack  of  inclination  to  deep 
respiration.  Markedly  extensive  pleural  involvement  with  the  exudation  of 
large  amounts  of  fibrin  causes  symptoms  resembling  those  of  acute  lobar 
pneumonia. 

As  a  rule  the  acute  symptoms  last  from  three  to  ten  days  but  unless  prompt 
and  proper  treatment  is  instituted  permanent  pleural  thickenings  and  ad- 
hesions remain  which  may  result  in  chronic  thoracic  pain  occurring  especially 
in  damp  weather. 

Diaphragmatic  pleurisy  may  resemble  peritonitis  in  its  symptoms  since 
the  pain  is  most  marked  along  the  costal  margin;  there  may  also  be  pain  and 
tenderness  in  the  upper  part  of  the  abdomen.  Mediastinal  pleurisy  is  very 
difficult  of  diagnosis. 

Physical  Signs.     Inspection  may  reveal  a  diminished  respiratory  excursion 


ACUTE    FIBRINOUS    PLEURISY.  657 

on  the  affected  side.  Palpation,  in  old  instances  with  permanent  adhesions, 
may  show  areas  of  an  mcrease  in  vocal  fremitus  due  to  its  transmission 
through  the  organized  tissue.  On  percussion,  if  there  is  a  considerable  exu- 
dation of  fibrin,  dulness  is  present  over  the  inflamed  area.  Ausadtation 
over  the  site  of  the  inflammation  reveals  the  most  typical  physical  sign 
of  the  lesion  which  is  the  presence  of  friction  sounds,  crepitant  or  subcrepi- 
tant  rales,  which  may  not  be  audible  unless  the  patient  breathes  deeply. 
The  voice  over  organized  adhesions  will  be  found  to  be  high  pitched. 

If  the  inflammation  involves  the  diapliragmatic  pleura  only,  the  patient 
should  be  examined  with  his  arms  extended  above  his  head.  This  fixes  the 
diaphragm  and  the  rales  may  be  heard  along  the  costal  attachment  of  this 
muscle.  Pressure  under  the  costal  margin  causes  these  rales  to  increase  in 
number  and  pressure  in  the  left  hypochondrium  may  cause  intense  pain 
(De  Mussey's  sign). 

Treatment.  In  the  milder  forms  of  the  disease  the  patient  need  not  be 
confined  to  bed,  but  if  there  is  much  pleural  involvement  and  a  febrile  move- 
ment this  precaution  is  necessary.  The  administration  of  antipyrine  salicylate 
(salipyrine)  in  doses  of  10  grains  (0.66)  every  two  to  fovir  hours  wiU  efi'ectually 
control  the  pain  as  a  rule,  and  inunctions  over  the  painful  area  three  times 
daily  of  a  drachm  (4.0)  of  an  ointment  composed  of  oil  of  turpentine,  salicylic 
acid  and  lanolin  of  each  I  drachm  (4.0)  and  simple  ointment  5  drachms  (20.0) 
will  usually  cause  absorption  of  the  exudate  and  obviate  the  formation  of 
lasting  adhesions.  Every  precaution  should  be  taken  to  break  these,  for,  if 
they  become  permanent,  the  lung,  owing  to  its  consequent  deficient  aeration, 
becomes  a  fertile  soil  for  tuberculous  infection.  Consequently  strapping 
of  the  chest  with  adhesive  plaster  should  never  be  employed,  for  while  it 
relieves  the  pain,  it  immobilizes  the  chest  and  allows  the  pleural  surfaces  to 
become  firmly  adherent.  Blisters  and  cupping  also  should  never  be  used  since 
they  increase  the  exudation  and  augment  the  possibility  of  the  formation  of 
permanent  adhesions.  Sodium  salicylate  may  be  given  by  mouth  instead  of 
salicylic  acid  by  inunction  but  the  former  has  no  advantages  over  the  latter 
method  and  the  salicylates  are  prone  to  disturb  digestion. 

If  the  pain  is  not  relieved  by  the  above  treatment,  various  local  applications 
in  the  form  of  compresses,  hot  or  cold — whichever  affords  more  relief — may  be 
prescribed.  Painting  the  painful  area  with  the  tinctiire  of  iodine  is  a  much 
employed  form  of  counter-irritation  and  anodyne  ointments  such  as  the 
following  may  be  found  to  have  a  field  of  usefulness:  I^  chloraU  hydrati, 
camphoraj,  aa  gr.  xv  (i.oo);  unguenti,  q.s.  ad  §i  (30.0).  Misce  et  signa — Ex- 
ternal use.  Or  I^  mentholis,  gr.  xv  (i.o);  cocainae  hydrochloridi,  gr.  v  (0.33); 
unguenti,  q.s.  ad   5i   (30-0).     Misce  et  signa — External  use. 

The  hypodermatic  injection  of  morphine  is  usuaUy  unnecessary  and  should 
be  employed  only  as  a  last  resort. 
42 


658  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Calomel  given  early  in  the  disease  is  said  to  diminish  the  exudation  of  the 
fibrin  and  to  prevent  the  inflammation  from  going  on  to  an  effusion  of  serum. 
Certainly  the  drug  can  do  no  harm. 

Sthenic  inflammations  with  high  temperature  at  the  onset  of  the  disease 
may  be  benefited  by  the  administration  of  aconite  or  veratrum  with  the  idea 
of  "bleeding  the  patient  into  his  own  tissues"  and  the  use  of  these  drugs  is 
certainly  preferable  to  the  more  drastic  procedure  of  venesection. 

Diaphoretics  are  recommended  by  certain  authorities  but  in  fibrinous 
pleurisy  they  seem  hardly  necessary,  however,  a  hot,  wet  pack  or  two  or  the 
pack  in  a  heated  sheet  covered  with  blankets  following  a  warm  bath,  may  make 
the  patient  more  comfortable.  The  use  of  pilocarpine  hypodermatically  in 
doses  of  I  of  a  grain  (0.008)  is  also  advocated  by  some  in  this  connection. 

The  chronic  adhesions  that  so  often  follow  this  form  of  pleurisy  as  well  as 
those  with  the  effusion  of  serum  or  pus,  are  best  treated  by  thoracic  massage, 
either  with  the  hand  or  with  the  vibrator,  and  by  means  of  respira- 
tory gymnastics  (see  p.  635).  Here  inunctions  of  iodine  vasogen  and  the 
internal  administration  of  iodine  in  the  form  of  potassium  iodide — gr.  x-xv 
(0.66-1.0)  three  times  a  day — or  better  the  syrup  of  hydriodic  acid — i  drachm 
(4.0)  before  each  meal — may  have  a  certain  influence  over  the  absorption 
of  the  organized  tissue  between  the  pleural  layers 

The  diet  in  mild  instances  of  fibrinous  pleurisy  may  consist  of  plain  and 
easily  digestible  solids  but  if  there  is  any  considerable  elevation  of  tempera- 
ture the  patient  would  best  be  restricted  to  fluids  while  this  lasts. 

ACUTE  SEROUS  PLEURISY. 

Synonyms.  Serous  Pleurisy;  Pleurisy  with  Effusion.  Pleuritis  with  Effu- 
sion. 

Definition.  An  acute  inflammation  of  the  pleura  accompanied  by  the 
exudation  of  fibrin  and  the  effusion  of  serous  fluid  into  the  pleural  sac. 

.Etiology.  There  is  a  considerable  tendency,  especially  on  the  part  of 
German  clinicians,  to  regard  all  instances  of  serous  pleurisy  as  tuberculous 
in  origin.  While  in  certain  patients  infection  with  the  bacillus  tuberculosis  is 
undoubtedly  responsible  for  the  incidence  of  this  inflammation  it  seems  hardly 
wise  to  make  so  sweeping  a  statement  as  the  above,  but  to  take  a  more  conserv- 
ative view.  It  is  probable  that  any  of  the  causes  of  fibrinous  pleurisy  may 
produce  the  serous  form  of  pleuritic  inflammation. 

Pathology.  The  lesion  involves,  as  a  rule,  most  of  the  pleura  of  one  or  both 
sides.  When  the  latter  is  the  case  the  pericardium  is  likely  to  share  in  the 
inflammation.  The  pleural  surfaces  are  coated  with  fibrin  and  gelatinous 
material  just  as  is  the  case  in  fibrinous  pleurisy,  and  in  addition  the  pleural 
cavity  contains  clear,  turbid  or  slightly  blood-tinged  scrum,  in  which  last  case 


ACUTE    SEROUS    PLEURISY.  659 

the  observer  should  suspect  the  presence  of  tuberculosis,  a  blood  dyscrasia 
or  the  existence  of  a  pulmonary  or  pleural  new  growth.  In  quantity  the  fluid 
may  reach  several  quarts  (litres). 

Microscopical  examination  of  the  exudate  reveals  leucocytes  in  small 
number,  at  times  red  blood  cells,  fibrin  and  endothelial  cells.  Chemical 
examination  shows  the  fluid  to  be  rich  in  albumin  and  sometimes  to  contain 
sugar,  urea  and  uric  acid.  A  fluid  of  high  specific  gravity,  1,012  to  1,024, 
containing  a  large  amount  of  fibrin  and  albumin,  with  an  accompanying 
lymphocytosis  is  very  probably  of  tuberculous  origin.  The  demonstration  of 
the  tubercle  bacillus  in  pleuritic  effusions  even  when  these  are  of  tuberculous 
origin,  is  difficult. 

The  presence  of  the  effusion,  if  in  sufficiently  large  amount,  causes  com- 
pression of  the  lung,  displacement  of  the  heart — a  large  exudation  into  the 
left  pleura  sometimes  pushing  this  organ  to  the  right  side  of  the  thorax — and 
of  the  abdominal  viscera. 

After  the  subsidence  of  the  inflammation  and  absorption  of  the  serum  and 
fibrin,  pleural  thickenings  and  adhesions  are  usually  left  behind  and  the 
compressed  lung  may  not  regain  its  normal  expansion,  as  evidenced  by  a  cer- 
tain amount  of  retraction  of  the  thoracic  wall  of  the  affected  side. 

Symptoms.  The  disease  may  begin  with  a  chill  followed  by  a  rise  in  tem- 
perature (ioi°-io3°  F. — 38.3°-39.5  C),  and  bodily  pain,  or  the  onset  may  be 
gradual,  with  malaise,  dry  cough  and  prostration.  There  is  likely  to  be  a  se- 
vere, knife-like  pain  which  may  be  over  the  inflamed  pleura  or  reflected  to  the 
opposite  side  of  the  chest  or  to  the  abdomen.  This  pain  is  increased  upon  respi- 
ration and  coughing.  The  respirations  are  accelerated  and  are  likely  to  be 
shallow  because  of  the  increased  pain  attendant  upon  deep  breathing.  As 
the  fluid  begins  to  exude  from  the  affected  pleural  surfaces  the  pain  usually 
subsides  but  the  breathing  remains  shallow,  now  because  of  the  diminishing 
ability  of  the  lung  to  expand.  The  acute  symptoms  now  gradually  grow 
less  marked  but,  unless  removed,  the  fluid  remains  for  days  or  weeks  before  it 
is  finally  absorbed. 

In  the  pleurisies  of  protracted  course  the  patient  may  not  seem  ill  enough 
to  be  confined  to  bed,  yet  he  loses  flesh  and  strength,  has  a  moderate  febrile 
movement  and  suffers  from  dyspnoea,  pain  in  the  chest  and  cough.  In  such 
instances  a  tuberculous  origin  of  the  inflammation  should  be  suspected  and 
frequent  physical  examinations  of  the  chest  should  be  most  critically  made. 

In  pleurisy  with  effusion,  especially  when  complicating  an  acute  infection, 
the  possibility  of  the  fluid  becoming  purulent  must  be  kept  in  mind. 

Physical  Signs.  Early  in  the  course  of  the  inflammation  before  the  exuda- 
tion of  the  serum  the  signs  are  those  of  a  dry  pleurisy.  (See  p.  657.)  After 
the  disappearance  of  the  fluid  there  are  likely  also  to  be  friction  sounds  heard 
over  the  resulting  pleuritic  adhesions.     While  the  fluid  is  present,  below  its 


66o  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

level  palpation  reveals  absence  of  vocal  fremitus  and  the  percussion  note  is 
flat.  Grocco's  sign,  a  triangular  area  of  dulness  upon  the  unaffected  side 
may  be  present.  This  area  is  bounded  by  the  line  of  the  spinous  processes 
of  the  vertebrae,  by  the  lower  limit  of  normal  pulmonary  resonance  and  by 
a  line  rising  from  this  boundary  to  the  median  line  at  or  about  the  upper 
limit  of  the  dulness  due  to  the  fluid.  The  base  of  this  triangle  is  from  one- 
half  to  one  inch  or  more  in  length.  Upon  auscultation  the  classical  signs  are 
absence  of  vocal  resonance  and  of  the  respiratory  murmur,  but  almost  as  fre- 
quently both  voice  and  breathing  are  bronchial;  aphonic  pectoriloquy  may 
be  present  (Baccelli's  sign).  At  the  level  of  the  fluid  the  percussion  note  is 
usually  dull  and  the  voice  and  breathing  are  bronchial  in  quality;  at  times 
aegophony  may  be  present.  Above  the  fluid  the  compressed  lung  gives 
normal,  highly  pitched  or  tympanitic  resonance  (Skoda's  sign)  and  the 
voice  and  breathing  are  normal;  more  rarely  they  are  broncho-vesicular  or 
bronchial.  Vocal  resonance  is  normal  or  slightly  intensified.  Measurement  is 
likely  to  show  an  increased  girth  of  the  affected  side,  and  examination  of  the 
heart  may  reveal  a  displacement  toward  the  unaffected  side.  Upon  Rontgen 
ray  examination  the  presence  of  the  fluid  may  cause  a  dark  shadow  in  the 
fluoroscopic  picture  or  upon  the  plate,  and  a  displacement  downward  of  the 
diapliragm. 

As  the  fluid  disappears  the  area  over  which  voice  and  breathing  are  audible 
extends  gradually  lower,  the  percussion  note  becomes  less  flat  and  finally 
dull.     The  dulness  is  likely  to  persist  owing  to  the  pleuritic  thickening. 

Sacculated  effusions  are  not  rare  but  when  small  may  escape  notice.  Their 
physical  signs  are  very  irregular.  The  use  of  the  exploring  needle  is  of  great 
assistance  in  diagnosis 

Treatment.  The  patient  should  be  kept  in  bed  and  on  a  light  but  nourish- 
ing diet.  Before  the  exudation  of  the  serum  the  treatment  described  for 
fibrinous  pleurisy  should  be  instituted  and  the  intestinal  tract  should  be 
cleared  by  the  use  of  calomel  in  divided  doses,  followed  by  a  saline. 

The  attempt  to  diminish  the  effusion  by  means  of  diuresis  and  purgation 
may  be  made  by  various  methods  of  which  perhaps  the  best  is  that  of  Matthew 
Hay.  Two  ounces  (60.0)  of  magnesium  sulphate  are  dissolved  in  an  equal 
amount  of  boiling  water;  the  mixture  is  allowed  to  cool  and  is  given  in  the 
evening.  The  patient  is  directed  to  drink  no  fluids  before  noon  of  the  next 
day.  Before  this  time  an  increase  in  the  excretion  of  urine  will  be  noticed, 
several  watery  stools  will  be  voided  and  the  quantity  of  pleuritic  fluid  may  be 
diminished.     This  medication  may  be  repeated  if  necessary. 

Other  diuretics  may  also  be  employed  such  as  the  Guy's  hospital  diuretic 
pill — calomel,  powdered  digitaHs  and  squill,  of  each  i  grain  (0.065), — caffeine, 
diuretin,  theocin,  etc.,  in  appropriate  dosage.  Ortner,  in  this  connection, 
speaks  of  the  use  of  urea — 5-10  grains  (0.33-0.66) — but  this  substance,  as 


ACUTE  SEROUS  PLEURISY.  66 1 

well  as  the  diuretics  mentioned  and  other  drugs  of  this  class,  will  usually 
be  found  to  have  only  a  Umited  influence  in  the  reduction  of  the  serous 
exudate. 

Diaphoretics  have  also  been  employed  with  the  hope  of  lessening  the  effu- 
sion but  their  influence  is  not  marked.  Hot  air  or  steam  baths  may  be  employed 
but  the  discomfort  which  they  are  likely  to  cause  more  than  over-balances 
any  benefit  that  may  accrue  from  their  use. 

The  salicylates,  because  of  their  influence  over  inflammations  of  serous 
membranes,  may  be  given  by  mouth  in  ordinary  dosage. 

Recently  much  research  into  the  influence  of  the  chlorides  of  the  diet  upon 
dropsical  conditions  has  been  carried  out  with  the  result  that  we  are  now  able 
to  facilitate  the  absorption  of  serous  exudates  and  transudates  by  means  of 
regulating  the  amount  of  these  substances  contained  in  the  ingested  food. 
All  serous  fluids  require  at  least  75  grains  (5.0)  of  sodium  chloride  to  the  quart 
(litre)  in  their  composition  to  prevent  their  osmosis  into  the  circulating  blood, 
consequently,  if  the  diet  is  so  arranged  that  it  shall  be  lacking  in  this  sub- 
stance such  osmosis  and  absorption  is  expedited.  In  view  of  this  fact  patients 
suffering  from  pleurisy  with  effusion  may  be  proper  subjects  for  this  form  of 
treatment  and  the  result  attained  may  justify  the  attempt. 

Certain  clinicians,  notably  Delafield,  assert  that  as  soon  as  fluid  enough 
to  give  physical  signs  has  accumulated,  it  should  be  drawn  off  by  thoracic 
paracentesis  as  a  curative  measure  without  waiting  for  the  evidences  of  respira- 
tory embarrassment,  but  more  conservative  observers  consider  that  the  opera- 
tion need  not  be  performed  until  these  manifestations  are  clear.  A  safe  rule 
by  which  to  be  guided  is  to  aspirate  when  the  respirations  exceed  twenty-four 
to  the  minute  without  waiting  until  the  fluid  becomes  a  mechanical  obstacle 
to  the  heart  action  and  breathing,  as  shown  by  marked  dyspnoea  and 
cyanosis. 

Technique  of  Thoracocentesis.  The  operation  may  be  performed  with 
various  forms  of  apparatus,  but  is  most  usually  done  with  the  Potain  aspirator 
which  is  too  weU  known  to  need  description.  A  stiU  simpler  method  is  to 
employ  a  large-mouthed  bottle  containing  about  two  quarts  (litres).  In  this 
a  vacuum  can  be  created  by  burning  a  drachm  (4.0)  or  two  of  alcohol. 
The  only  other  appliances  necessary  are  a  few  feet  of  rubber  tubing,  to  one 
end  of  which  the  aspirating  needle  is  attached  while  its  other  end  is  fixed  to  a 
glass  tube  which  penetrates  the  cork  fitted  to  the  bottle,  and  an  artery  clamp. 
All  the  joints  must  be  air  tight.  To  use  this  form  of  aspirator  the  air  should 
be  exhausted  from  the  bottle  and  the  cork  inserted.  The  needle  is  plunged 
into  the  chest,  the  artery  clamp  removed  from  the  tube  and  the  fluid  allowed 
to  run.  A  needle  of  fairly  large  calibre  should  be  employed,  for,  especially 
if  the  operation  is  done  late  in  the  disease,  the  albuminous  flocculi  which 
may  be  contained  in  the  exudate  are  likely  to  get  into  the  needle  and  stop  it. 


662  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

The  procedure  must  be  carried  out  in  the  strictest  accordance  with  the 
principles  of  asepsis.  The  hands  of  the  operator  must  be  steriHzed,  the  needle 
freshly  boiled  and  the  patient's  skin  prepared  as  for  a  surgical  operation,  for 
not  infrequently  a  serous  pleurisy  has  been  converted  into  an  empyema  by 
the  faulty  technique  of  the  operator,  an  accident  which,  it  is  needless  to  say, 
should  never  occur.  The  proper  precautions  having  been  taken  and  the  point 
selected  for  puncture — usually  the  first  intercostal  space  below  the  angle  of 
the  scapula — anaesthetized  by  the  ethyl  chloride  or  aether  spray,  the  patient 
sits  up  in  bed  and  is  told  to  place  the  hand  of  the  affected  side  upon  his  head, 
in  order  to  raise  the  scapula  and  widen  the  spaces  between  the  ribs  as  far  as 
possible;  the  needle  is  gently  but  firmly  forced  through  the  wall  of  the  chest 
into  the  fluid-containing  cavity.  After  a  little  experience  it  is  easy  to  tell 
whether  the  needle  is  in  the  fluid  or  has  penetrated  the  lung — an  accident 
upon  which,  fortunately,  no  bad  results  are  attendant.  The  needle  now  being 
in  the  effusion,  this  is  allowed  to  run  into  the  bottle.  If  the  fluid  is  in  large 
quantity  it  is  unwise  to  remove  it  at  one  sitting,  since  there  may  be  a  certain 
amount  of  shock  attendant  upon  the  displaced  lung  and  heart  being  suddenly 
allowed  to  resume  their  normal  positions,  but  it  is  better  to  wait  until  another 
day  before  draining  the  pleura  completely.  During  the  procedure  the  patient's 
pulse  and  general  condition  should  be  carefully  observed  and  upon  the  appear- 
ance of  any  untoward  symptom  the  needle  should  be  at  once  withdrawn.  As 
the  quantity  of  fluid  flows  off,  at  times,  the  patient  develops  a  cough,  which, 
if  it  is  frequent  or  distressing,  is  an  indication  that  no  more  fluid  should  be 
removed.  The  needle  being  withdrawn  the  puncture  should  be  dressed  with 
a  bit  of  sterile  gauze  or  cotton  held  in  place  by  a  strip  of  adhesive  plaster. 

In  certain  patients  re-accumulation  of  the  fluid  may  render  necessary  one  or 
more  repetitions  of  the  operation;  in  the  prevention  of  this  occurrence  deple- 
tion by  means  of  diuretics  and  purgatives  is  likely  to  be  found  useful. 

Counter-irritation  in  pleurisy  with  effusion  may  relieve  the  pain  to  some 
extent  but  it  is  doubtful  if  it  has  any  influence  upon  the  disease  itself.  Such 
means,  however,  as  painting  the  chest  with  tincture  of  iodine  pure  or  in  collo- 
dion (one  part  in  ten)  or  inunctions  with  iodine- vasogen  may  be  employed; 
the  latter  being  especially  useful  in  the  adhesions  and  thickenings  which  result 
after  the  disappearance  of  the  fluid.  (See  also  p.  667.)  After  this  has  taken 
place,  if  the  effusion  has  been  large  and  the  lung  has  been  subjected  to  con- 
siderable compression,  the  expansion  of  the  organ  will  be  facflitated  by  the 
employment  of  such  pulmonary  gymnastics  as  those  described  in  the  section 
devoted  to  the  treatment  of  emphysema  (q.  v.)  or  the  use  of  the  so-called 
James'  bottles.  A  simpler  means  consists  in  taking  as  deep  inspirations  as 
possible  and  forcibly  blowing  out  the  inspired  air  through  a  bit  of  glass  tubing 
or  a  pipe  stem. 

During  convalescence  the  patient's  food  should  be  of  the  most  nourishing 


EMPYEMA.  663 

character  and  tonics,  such  as  codliver  oil,  iron,  the  vegetable  bitters,  etc., 
should  be  prescribed. 

Oftentimes  recovery  will  be  accelerated  by  a  change  of  climate,  the  most 
preferable  being  one  of  mild  temperature  and  dry  atmosphere. 

EMPYEMA. 

Synonyms.  Pleurisy  with  Purulent  Effusion;  Purulent  Pleurisy;  Purulent 
Pleuritis;  Pyothorax. 

Definition.  An  inflammation  of  the  pleura  characterized  by  the  exudation 
of  fibrin  upon  the  pleural  surfaces  and  of  purulent  fluid  into  the  pleural  cavity. 

.Etiology.  The  disease  may  be  primary  following  exposure  but  it  is 
more  usually  secondary  to  a  serous  pleurisy,  to  inflammations  of  the  lungs  or 
to  abscesses  of  the  chest  wall,  the  lung,  the  liver  or  of  the  abdomen,  which 
have  ruptured  into  the  pleural  cavity. 

Pathology.  Empyema  usually  involves  the  entire  pleural  cavity  of  one  or 
both  sides,  but  it  may  affect  only  a  limited  portion  of  the  pleura,  in  which 
case  the  inflammation  is  said  to  be  sacculated.  The  affected  pleura  is  covered 
with  fibrin  and  pus  and  is  frequently  much  thickened.  Its  cavity  contains 
in  its  lowest  portion  purulent  fluid,  in  greater  or  less  amount,  which  pushes 
the  lung  upward  and  compresses  the  organ  to  a  greater  or  less  degree  depend- 
ing upon  the  quantity  of  the  exudate.  Circumscribed  collections  of  pus  may 
occur  in  any  part  of  the  pleural  sac;  communication  may  exist  between  the 
pleura  and  the  lung,  and  pus  may  escape  into  this  organ  and  be  expectorated 
or  the  pus  may  escape  through  a  rupture  in  the  wall  of  the  thorax. 

Examination  of  the  fluid  shows  it  to  contain  many  pus  cells,  more  or  fewer 
red  blood  cells,  and  various  micro-organisms  of  which  staphylococci,  strep- 
tococci and  either  of  the  varieties  of  pneumonia  bacilli  are  the  most  common. 

Symptoms.  In  the  primary  infections  the  onset  of  the  inflammation  is 
marked  by  a  chill,  followed  by  a  rise  in  temperature  and  prostration  usually 
more  marked  than  those  of  serous  pleurisy.  There  are  general  pains,  dry 
cough,  dyspnoea,  and  pain  in  the  chest,  especially  upon  deep  inspiration. 
Death  may  occur  within  a  few  weeks  from  septic  poisoning  or  the  inflam- 
mation may  become  chronic. 

When  the  disease  is  secondary  to  pleurisy  w'ith  effusion  the  onset  of  the 
purulent  inflammation  is  more  gradual  and  is  marked  by  increasing  prostra- 
tion and  a  temperature  of  septic  type.  A  pneumonia  may  run  directly  on  to 
empyema  or  the  symptoms  of  the  latter  condition  may  not  appear  until  defer- 
vescence has  taken  place  and  convalescence  has  become  established.  In  the 
latter  event  the  patient  will  exhibit  a  sudden  rise  of  temperature,  an  increase 
of  the  prostration,  and  physical  examination  will  reveal  the  signs  of  pleuritic 
fluid. 


664  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

If  the  disease  passes  on  into  the  chronic  stage  it  may  last  for  months  or 
years;  the  patient  loses  flesh  and  strength,  suffers  from  shortness  of  breath, 
has  more  or  less  cough  and  a  septic  temperature.  There  may  be  rupture 
into  the  lung  and  expectoration  from  time  to  time  of  pus  in  greater  or  less 
quantity,  or  the  pus  may  be  discharged  outward  through  the  wall  of  the  chest. 
In  some  instances  the  inflammation  may  become  gangrenous  and  death  from 
pyemia  may  result.  In  the  chronic  condition  the  patient  may  improve,  but  there 
is  usually  some  pus  left  in  the  pleural  cavity,  either  free  or  circumscribed,  and 
infection  with  the  tubercle  bacillus  is  a  frequent  occurrence.  If  this  does 
not  take  place  the  subject  continues  in  a  state  of  chronic  sepsis  and  becomes 
"more  and  more  weak  until  relieved  by  death.  Without  proper  treatment 
recovery  seldom  or  never  takes  place. 

Physical  Signs.  These  are  usually  identical  with  those  of  serous  pleurisy 
but  irregularities  are  frequently  noticed.  The  observer  should  not  be  deceived 
by  the  existence  of  rales  and  friction  sounds  below  the  level  of  the  fluid,  since 
these  may  occur,  and  when  the  diagnosis  is  doubtful,  it  is  the  part  of  wisdom 
to  use  the  exploring  needle.  The  signs  of  sacculated  empyema  are  especially 
likely  to  be  such  as  to  cause  doubt  and  here  the  aspirating  needle  should  be 
used  without  hesitation  as  a  means  of  making  the  diagnosis  certain. 

Treatment.  This  is  essentially  surgical.  The  treatment  by  means  of 
simple  aspiration  may  be  attempted  in  the  case  of  children,  but  in  adults  it 
is  practically  useless.  Here  the  chest  must  be  opened,  one  or  more  ribs 
resected  and  the  fluid  removed.  In  children  also,  if  the  fluid  re-accumulates 
after  several  attempts  at  cure  by  tapping,  the  more  radical  treatment  be- 
comes necessary. 

Sacculated  collections  of  pus  may  not  recur  after  aspiration,  consequently 
it  is  wise  to  employ  this  means  tentatively,  introducing  the  needle  at  the 
point  of  maximum  flatness. 

When  the  amount  of  fluid  is  considerable,  preliminary  thoracocentesis 
should  always  be  done,  since  the  sudden  removal  of  a  large  quantity  of  fluid 
and  its  consequent  pressure  upon  the  vital  organs,  is  likely  to  result  in  shock 
of  no  little  intensity.  FoUowing  this  procedure  the  radical  operation  should 
be  performed.  The  interval  may  be  from  a  few  hours  to  a  day  or  two,  depend- 
ing on  the  condition  of  the  patient. 

The  technique  of  the  operation  should  be  adapted  to  the  patient  in  hand. 
In  children  simple  incision  of  an  intercostal  space  may  be  all  that  is  required 
but  more  usually  it  will  be  found  necessary  to  remove  a  section  of  one  or  more 
ribs  in  order  that  the  pleural  cavity  may  be  thoroughly  cleared  of  the  products 
of  the  inflammation. 

Simple  incision  is  usually  performed  in  the  fourth  or  fifth  space  or  over 
the  point  of  maximum  flatness;  its  anterior  extremity  should  be  well  forward, 
at  least  as  far  as  the  anterior  axillarv  line  and  it  should  be  continued  backward 


EMPYEMA,  665 

for  two  or  three  inches.  The  skin,  intercostal  muscles  and  finally  the  pleura 
are  divided,  the  incision  is  widened  as  much  as  possible  and  the  pus  is  allowed 
to  flow  slowly  out,  in  order  that  sudden  relief  of  the  intra-thoracic  pressure 
may  not  interfere  with  the  action  of  heart  and  lungs. 

Following  the  evacuation  of  the  pus  the  fingers  should  be  introduced  and 
all  shreds  of  fibrin,  albuminous  coagula,  etc.,  removed.  Most  clinicians  agree 
that  irrigation  of  the  pus  cavity  is  harmful  rather  than  beneficial.  The  pleura, 
having  been  cleansed,  drainage  tubes  of  proper  calibre  and  length  (two,  pref- 
erably, which  will  provide  against  the  interference  with  free  drainage  should 
one  become  stopped)  are  inserted  and  the  wound  is  dressed.  The  outer  end 
of  each  tube  should  be  transfixed  with  a  safety-pin  with  a  cord  attached  to 
prevent  its  entrance  into  the  pleural  cavity.  A  small  wad  of  gauze  should 
be  about  the  tube  between  the  pin  and  the  chest  wall  lest  traumatism  take 
place.  A  small  quantity  of  iodoform  powdered  upon  tubes  and  dressing  will 
assist  in  preventing  putrefaction  and  will  hasten  the  healing  process.  This 
substance  may  also  be  sprinkled  through  the  incision  but  care  should  be  taken 
to  provide  against  any  possibility  of  intoxication;  20  to  40  grains  (1.33  to  2.66) 
may  be  employed  without  apprehension  and  later  a  smaller  amount  will 
suffice.  The  dressing  should  contain  plenty  of  absorbent  material,  for  the 
discharge,  at  any  rate  at  first,  is  considerable.  Following  the  operation  the 
dressings  should  be  changed  daily — oftener  if  necessary — but  as  the  healing 
process  progresses  the  intervals  may  be  longer.  The  patient  should  be  care- 
fully watched  and  any  rise  in  temperature  usually  signifies  an  interference 
with  free  drainage  and  necessitates  examination  of  the  condition  of  the  wound. 

As  the  lung  expands  and  the  pus  cavity  proceeds  toward  healing  the  tubes 
should  be  shortened  from  time  to  time  until  finally  a  drain  of  iodoform  gauze 
may  be  substituted.  Before  removing  the  tubes  one  should  make  certain 
that  no  fistulous  tracts  or  sinuses  remain  and  that  the  pleural  cavity  is  properly 
obliterated. 

The  more  radical  operation  of  exsection  of  portions  of  one  or  more  ribs, 
by  some  authorities,  is  considered  preferable  to  the  intercostal  incision.  The 
rib  removed  is  usually  the  sixth,  seventh  or  eighth  and  of  this  from  a  few 
inches  to  its  whole  length  are  resected  subperiosteally,  removed,  and  the  pleura 
is  incised  and  drained  as  in  the  operation  by  simple  incision.  At  times  it  be- 
comes necessary  to  remove  parts  of  two  or  more  ribs,  and  as  a  secondary 
operation,  in  rare  instances  a  thoracoplasty  is  indicated. 

The  operations  described  above  are  usually  performed  under  general 
anaesthesia  but  that  of  pleural  incision  may  be,  when  desirable,  done  under 
the  influence  of  a  local  anaesthetic.  It  should  be  unnecessary  to  state  that  in 
these  as  in  all  other  operations  the  strictest  aseptic  precautions  must  be  observed. 

After  operation  the  obliteration  of  the  pleural  cavity  takes  place  in  varying 
lengths  of  time.     It  may  close  within  a  week  or  two  or  a  discharging  sinus 


666  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

may  persist  for  months.  The  after-treatment  consists  of  the  employment  of 
all  means  suitable  to  maintain  the  strength  of  the  patient,  such  as  generous 
diet,  comprising,  among  other  articles,  plenty  of  milk  and  cream,  the  admin- 
istration of  codliver  oil,  iron  and  other  tonics  as  indicated,  and  fresh  air.  Before 
the  patient  can  leave  his  room  he  should  be  dressed  as  if  for  out-of-doors 
and  the  windows  should  be  thrown  open  for  several  hours  each  day;  when 
able  to  walk  he  should  be  encouraged  to  seek  the  open  air  as  much  as 
possible.     Much  benefit  often  accrues  from  a  change  of  climate. 

Respiratory  exercises  calculated  to  expand  the  lung,  such  as  those  described 
under  the  treatment  of  serous  pleurisy,  should  be  ordered. 

In  instances  which  continue  the  discharge  of  purulent  fluid  from  the  pleura 
for  a  protracted  period  the  employment  of  inunctions  with  unguentum  Credd 
may  favorably  influence  the  suppurative  process. 

CHRONIC  ADHESIVE  PLEURISY. 

Synonym.     Chronic  Adhesive  Pleuritis. 

Definition.  A  chronic  inflammatory  condition  of  the  pleural  surfaces 
characterized  by  the  production  of  connective  tissue  adhesions. 

.Etiology.  Chronic  adhesive  pleurisy,  usually,  is  a  sequela  of  the  adhe- 
sions resulting  from  attacks  of  fibrinous,  serous  or  piirulent  pleurisy.  It 
may  follow  acute  pneumonia  or  complicate  tuberculous  inflammations  of  the 
lungs.     In  certain  patients  the  lesion  seems  to  be  primary. 

Pathology.  The  connective  tissue  growth,  as  a  rule,  begins  in  the  cica- 
tricial adhesions  which  previous  pleuritic  inflammations  have  left  behind  and 
progresses  until  more  or  less  of  the  surface  of  one  or  both  lungs  is  firmly  at- 
tached to  the  chest  waU.  These  adhesions  are  often  so  firm  that  the  greatest 
difficulty  may  be  experienced  in  separating  them.  There  may  be  displace- 
ment of  the  heart,  contraction  of  the  wall  of  the  thorax  or  spinal  curvature, 
as  a  result  of  the  contraction  of  this  growth  of  connective  tissue. 

Symptoms.  Early  in  the  disease,  before  the  adhesions  have  involved  any 
great  amount  of  the  pleural  surface,  there  may  be  merely  slight  dyspnoea, 
pain  in  the  chest,  increased  on  inspiration,  and  cough.  As  the  inflammation 
progresses  these  symptoms  become  more  marked,  there  is  interference  with 
the  heart  action,  due  to  the  adhesions,  and  consequent  displacement  of  the 
organ,  and  the  patient  becomes  weak  and  emaciated  and  an  easy  prey  for  any 
intercurrent  affection. 

Physical  Signs.  Over  the  adhesions  the  percussion  note  is  dull,  the  voice 
and  breathing  are  harsh  and  intensified  and  there  are  sounds  due  to  the 
friction  of  the  pleural  surfaces. 

Treatment.  This  consists  in  avoiding  exposure  to  cold  and  dampness  as 
much  as  possible  and  when  practicable,  advising  life  in  the  open  air  in  a 


HYDROTHORAX.  667 

climate  where  pulmonary  affections  are  uncommon.  Pulmonary  gymnastics, 
respiratory  exercises  and  thoracic  massage  (see  p.  648)  will  be  found  useful 
in  combating  the  interference  with  respiration.  The  patient's  nutrition 
should  be  kept  up  by  means  of  a  generous  and  easily  digestible  diet  contain- 
ing plenty  of  milk  and  cream,  and  the  administrations  of  such  tonics  as  cod- 
liver  oil,  iron  in  appropriate  form  and  the  vegetable  bitters.  The  heart 
weakness  may  require  the  use  of  strychnine.  For  the  pleuritic  pain  counter- 
irritant  liniments  and  ointments  may  be  employed.  An  excellent  liniment 
may  be  made  by  triturating  hydrated  chloral,  camphor  and  menthol  in 
equal  parts.  Inunctions  of  iodine-vasogen  ointment  with  a  view  to  possible 
absorption  of  the  adhesions  may  be  prescribed. 

In  certain  instances  of  contracted  chest  resulting  from  adhesions  follow- 
ing empyema,  relief  may  be  sought  at  the  hands  of  the  surgeon. 

HYDROTHORAX. 

Definition.     An  accumulation  of  serum  within  the  pleural  cavity. 

.Etiology.  This  condition  is  a  frequent  accompaniment  of  anasarca  due 
to  any  cause,  the  most  usual  ones  being  nephritis  or  chronic  endocarditis. 
The  effusion  is  a  non-inflammatory  one  and  therefore  a  transudate  rather 
than  an  exudate.  It  is  the  result  of  an  interference  with  the  proper  circula- 
tion of  the  blood  through  the  pleural  membranes.  The  transudate  is  usually 
bilateral  but  this  is  not  always  the  case. 

Symptoms  and  physical  signs  are  identical  with  those  of  pleurisy  with 
the  effusion  of  serum  but  there  is  likely  to  be  less  pain  and  there  may  be  no 
febrile  movement. 

Treatment  will  be  considered  under  the  treatment  of  the  causative  con- 
ditions. 

HYDROPNEUMOTHORAX ;  PYOPNEUMOTHORAX. 

Definition.  A  condition  characterized  by  the  presence  of  air  and  fluid, 
which  may  be  purulent,  in  the  pleural  cavity. 

.Etiology.  Hydropneumothorax  or  pyopneumothorax  is  the  result  of  a 
perforation  of  the  pleural  cavity  resulting  from  wound  or  disease  of  the  chest 
wall;  the  rupture  of  some  pulmonary  lesion  such  as  an  abscess,  tuberculous 
cavity,  infarct,  gangrenous  condition,  etc.;  the  rupture  through  the  diaphragm 
into  the  pleural  cavity  of  some  inflammatory  process  due  to  malignant  neo- 
plasm of  the  oesophagus,  stomach  or  intestine;  the  rupture  of  an  empyema 
into  the  lung,  or  it  may  be  caused  by  an  empyema  due  to  infection  with  some 
gas-generating  micro-organism  such  as  the  hacilliis  arogenes  capsulatiis. 


668  DISEASES  or  the  respiratory  system. 

Symptoms.  The  patient  suffers  from  the  symptoms  of  the  causative 
lesion  and  at  the  time  the  rupture  takes  place  complains  of  suddenly  increased 
pain  and  difficulty  in  breathing.  There  may  be  a  sensation  of  something 
giving  way  in  the  thorax.  At  times  the  symptoms  of  collapse,  great  prostra- 
tion, rapid  and  feeble  heart  action  and  subnormal  temperature,  may  be  present. 
In  such  instances  death  may  rapidly  supervene.  In  other  patients  the  symp- 
toms of  collapse  become  ameliorated  but  the  ultimate  prognosis,  especially  when 
tuberculosis  is  present,  is  bad.  There  are  gradual  loss  of  flesh  and  strength 
and  dyspnoea,  at  times  so  severe  that  the  patient  insists  upon  sitting  up  in  bed. 
There  is  a  febrile  movement;  when  pus  is  present  the  typical  irregular  curve 
of  suppurative  conditions  is  observed.  The  course  of  the  disease  in  these 
latter  instances  markedly  resembles  that  of  empyema. 

Physical  Signs.  Inspection  and  mensuration  show  one  side  of  the  chest  to  be 
larger  than  the  other.  The  intercostal  spaces  may  be  obliterated  and  the 
respiratory  movement  of  the  thorax  is  slight.  Upon  palpation  the  vocal 
fremitus  is  found  to  be  much  diminished  or  absent.  The  percussion  note 
above  the  fluid  may  be  hyper-resonant,  tympanitic  or  more  rarely  dull;  below 
the  fluid  it  is  flat.  Auscultation  above  the  fluid  reveals  amphoric  breathing 
or  a  feeble  or  absent  vesicular  murmur;  the  voice  is  usually  bronchial  or  ampho- 
ric in  quality.  Below  the  level  of  the  fluid  voice  and  breathing  are  usually 
absent.  If  the  ear  is  placed  upon  the  chest  just  below  the  scapula  of  the 
affected  side  and  the  patient  is  shaken  the  splashing  sound  known  as  succus- 
sion  will  be  heard,  which  is  a  pathognomonic  sign  of  this  condition.  The 
so-called  metallic-tinkle,  the  result  of  drops  of  fluid  falling  from  the  perfora- 
tion into  the  fluid  below,  may  be  heard.  With  the  ear  at  the  back  of  the  chest 
the  clink  of  a  coin  placed  against  the  front  of  the  chest  and  tapped  by  another 
coin,  may  be  heard.  This  sign  is  usually  pathognomonic  of  hydropneumo- 
thorax  although  it  may  be  present  over  bronchiectases. 

Treatment.  The  patient  should  be  confined  to  bed  and  fed  upon  a  nourish- 
ing fluid  diet.  The  pain  may  be  so  severe  as  to  require  the  hypodermatic 
administration  of  morphine.  When  less  severe  it  may  be  controlled  by  coun- 
ter-irritation (see  p.  667).  The  heart  weakness  may  be  relieved  by  stimula- 
tion by  means  of  strychnine  and  alcohol.  The  dyspnoea  may  be  lessened 
by  allowing  the  patient  to  sit  up  in  bed  and  by  inhalations  of  oxygen.  Marked 
dyspnoea  and  oppression  may  be  relieved  by  tapping  the  chest  above  the  level 
of  the  fluid.  A  needle  of  large  calibre  to  which  a  rubber  tube  is  attached 
should  be  used,  but  no  aspirating  apparatus.  The  pressure  within  the  chest 
will  cause  the  expulsion  of  the  air  during  inspiration,  and  to  prevent  its  re- 
entrance  during  expiration,  the  finger  should  be  applied  to  the  end  of  the 
tube,  or  this  should  be  placed  under  water  contained  in  a  bottle  arranged  for 
the  purpose.  If  the  air  continues  to  re-accumulate  a  drainage  tube  may  be 
permanently  fixed  in  the  chest  wall. 


HEMOTHORAX.  669 

Aspiration  of  the  fluid,  if  it  is  serous,  may  bring  about  improvement,  but, 
when  the  fluid  is  purulent,  is  Hkely  to  result  in  only  temporary  relief. 

Operative  procedures  may  be  employed  with  the  hope  of  obliterating  the 
pleural  cavity. 

HiEMOTHORAX. 

Synonym.     Haematothorax. 

Definition.     An  accumulation  of  blood  within  the  pleural  cavity. 

^Etiology.  Blood  in  the  pleural  cavity  may  result  from  the  rupture  of  an 
aneurysm,  or  from  wounds  of  the  blood-vessels  of  the  neighboring  parts.  It 
may  be  due  to  malignant  neoplasms  of  the  lung  or  pleura  or  it  may  take  place 
during  the  course  of  any  of  the  haemorrhagic  diseases  or,  very  exceptionally, 
during  pulmonary  tuberculosis,  particularly  in  children. 

Symptoms  and  Physical  Signs  are  those  of  hydrothorax. 

The  prognosis.  This  depends  upon  the  cause  but  it  is  usually  very  unfa- 
vorable. 

Treatment  is  that  of  the  astiological  factor  combined  with  the  aspiration 
of  the  fluid. 

NEOPLASMS  OF  THE  PLEURA. 

While  new  growths  of  the  pleura  are  uncommon,  this  membrane  may  be 
the  seat  of  carcinomatous  involvement.  As  a  rule  pleural  carcinoma  is  secon- 
dary, having  spread  directly  from  a  primary  tumor  of  the  lung;  more  rarely 
it  may  be  metastatic  as  a  result  of  neoplasms  of  other  parts  of  the  body — notably 
lung  or  breast. 

Primary  pleural  sarcoma  may  occur  and  from  it  metastases  may  be  depos- 
ited in  other  organs  and  tissues. 

Symptoms  and  Physical  Signs.  Those  of  either  carcinoma  or  sarcoma 
resemble  the  symptoms  and  physical  signs  of  a  chronic  pleurisy  and  the 
differential  diagnosis  may  not  be  made  before  the  appearance  of  the  cachexia 
typical  of  malignant  disease,  or  of  symptoms  referable  to  the  establishment 
of  metastatic  growths  in  other  parts.  The  pulmonary  symptoms  accompany- 
ing pleural  neoplasm  are  comparatively  insignificant.  Bloody  effusion,  if 
present,  is  suggestive  of  new  growth  and  examination  of  the  effusion  may  in 
rare  cases  reveal  the  presence  of  cells  typical  of  carcinoma  or  sarcoma. 

Treatment.  This  consists  in  the  relief  of  the  distressing  symptoms  by 
means  of  the  aspiration  of  collections  of  fluid  which  interfere  with  lung  and 
heart  action,  stimulation — alcohol,  strychnine,  etc.,  as  indicated — and  the 
maintenance  of  the  patient's  strength,  in  so  far  as  is  possible,  by  means  of 
nourishmg  food.  If  pain  is  a  feature  of  the  condition  morphine  may  be  given 
hypodermatically. 


670  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

The  use  of  the  Rontgen  ray,  radium  or  any  of  the  vaunted  anti-cancer 
sera  may  be  undertaken  but  it  is  wise  to  inform  the  patient  how  little  reliance 
may  be  placed  upon  these  forms  of  treatment. 

Non-malignant  tumors  of  the  pleura  such  as  lipotnata  and  enchondromata 
have  been  observed. 

The  pleura  is  also  subject  to  hydatid  or  echinococcus  disease.  The  occur- 
rence of  this  condition  is  rare  and  usually  the  first  noticed  symptoms  are 
those  due  to  the  presence  of  pleuritic  effusion.  The  fluid  is  usually  serous, 
more  rarely  purulent.  The  serous  fluid  of  hydatid  disease  contains  no  albu- 
min. The  presence  in  the  fluid  of  fragments  of  cysts  and  of  booklets  is  the 
only  incontrovertible  evidence  of  this  condition 

The  treatment  consists  in  aspiration  to  relieve  the  symptoms  of  compres- 
sion of  the  lung.     Surgical  intervention  is  unsatisfactory. 

DISEASE  OF  THE  MEDIASTINUM. 

Under  this  heading  are  classed  the  pathological  conditions  which  may 
affect  the  contents  of  the  mediastinal  space,  excepting  affections  of  the  heart, 
aorta,  trachea  and  oesophagus. 

Various  types  of  tumors  may  develop  in  the  mediastinum;  of  these  the 
most  important  are: 

I.  Carcinoma  and  Sarcoma.  These  may  be  either  primary  or  secondary, 
the  sarcomata  being  more  often  primary  than  the  carcinomata.  The  former 
begin  in  the  remnant  of  the  thymus  gland,  in  the  lymphoid  structures  which 
are  numerous  in  this  situation,  or  are  secondary  to  sarcomatous  growths  of 
neighboring  tissues;  the  mediastinal  glands  may  also  furnish  a  starting  point 
for  primary  carcinomata.  Secondary  carcinomata  develop  as  a  result  of 
primary  growths  in  the  breast,  lungs,  stomach,  plem-a  or  more  remote  struc- 
tures; they  are  seldom  of  large  size. 

Symptoms.  Small  growths  may  not  give  any  evidence  of  their  presence; 
when  symptoms  are  manifest  they  are  those  of  pressure.  Dyspnoea  is  early 
and  constant,  it  may  be  due  either  to  pressure  upon  the  trachea,  heart  and 
great  vessels,  or  upon  the  recurrent  laryngeal  nerves.  In  the  latter  instance 
hoarseness,  loss  of  voice  and  the  peculiar  brassy  cough;  which  is  so  character- 
istic of  thoracic  aneurysm,  are  also  present.  Pressure  upon  the  thoracic 
vessels  results  in  distention  of  the  veins  of  the  upper  part  of  the  body  with 
accompanying  coldness,  cyanosis  and  oedema  of  the  hands,  and  sometimes 
clubbing  of  the  fingers.  The  distended  veins  may  be  tortuous  and  even  almost 
varicose  in  appearance.  There  may  be  inequality  of  the  radial  pulses  due  to 
pressure  upon  the  arteries.  Pressure  upon  the  sympathetic  nerves  causes 
pupillary  inequality.  (Esophageal  compression  results  in  dysphagia.  Pleu- 
ritic and  pericardial  effusions  may  be  present.     In  marked  instances  of  the 


DISEASE    OF    THE    MEDIASTINUM.  67 1 

affection,  the  growth  may  be  so  large  as  to  nearly  fill  the  thoracic  cavity,  the 
lungs  and  heart  being  pushed  far  out  of  their  normal  situations. 

Tumors  in  the  middle  and  posterior  mediastina  sometimes  cause  a  cough, 
paroxysmal  and  whooping  in  character,  from  pressure  upon  the  vagus  nerve; 
with  this  cough  there  may  be  muco-purulent  or  blood-streaked  sputum;  dys- 
phagia is  sometimes  marked  but  may  be  absent.  Pressure  upon  the  pneumo- 
gastric  nerve  is  also  said  to  cause  cardiac  palpitation,  arrhythmia  and  attacks 
of  faintness.  Compression  of  the  azygos  veins  may  result  in  oedema  of  the 
upper  abdomen  and  in  transudation  of  serum  into  the  pleurae. 

Growths  which  are  secondary  to  tumors  of  the  lungs  or  pleurae  are  less 
apt  to  cause  marked  pressure  symptoms  but  there  is  more  frequently  fluid  in 
the  pleural  cavities  and  the  cervical  lymph  glands  may  be  enlarged.  There 
is  usually  more  or  less  cachexia,  especially  when  there  is  associated  involve- 
ment of  the  pleura  or  lung. 

Physical  Signs.  Growths  in  the  anterior  mediastinum  may  cause  a  bulg- 
ing or  an  erosion  of  the  sternum.  Upon  palpation  the  vocal  fremitus  is 
sometimes  exaggerated,  sometimes  diminished.  Pulsation  may  be  noted  but 
is  not  of  the  expansile  type  which  characterizes  aneurysm.  If  the  lesion  is 
situated  high  in  the  mediastinal  space  it  may  be  felt  above  the  manubrium, 
if  its  situation  is  low  it  may  be  palpable  in  the  xiphoid  notch.  The  percussion 
note  over  the  tumor  is  dull,  the  area  of  dulness  corresponding  in  some  degree  in 
size  and  shape  to  that  of  the  growth;  it  is  usually  somewhat  irregular  in  extent. 
Auscultation  over  the  dull  area  may  reveal  nothing,  but  at  times  the  breathing 
and  heart  sounds  are  distinctly  audible;  a  ventriculo-systolic  murmur  may  be 
present  due  to  pressure  upon  the  vessels  at  the  cardiac  base.  There  may  be 
a  friction  sound  over  the  sternum  when  the  arms  are  raised  (Perez's  sign). 

Tumors  of  the  middle  and  posterior  portions  of  the  mediastinum  are  evi- 
denced by  few  physical  signs  other  than  dulness  upon  percussion  and  modi- 
fication of  the  respiratory  signs. 

The  diagnosis.  Thoracic  aneurysm  resembles  in  many  particulars  the 
condition  under  consideration  but  in  mediastinal  disease  the  course  of  the 
affection  is  much  more  rapid  and  the  symptoms  of  venous  obstruction  are 
much  more  pronounced;  the  cachexia  is  more  marked  and  the  tumor  seldom 
possesses  an  expansile  pulsation.  Erosion  of  bone  with  its  accompanying 
pain  is  more  common  in  the  case  of  aneurysm,  the  tracheal  tug  is  often  present 
and  the  characteristic  diastolic  shock  may  usually  be  both  felt  and  heard;  in 
tumor  this  is  said  to  be  never  present.  Mediastinal  growths  are  more  common 
in  those  of  advanced  years,  except  in  the  case  of  sarcoma,  which  may  develop 
in  youth,  and  may  be  associated  with  tumors  of  other  parts;  laryngoscopic 
examination  may  give  evidence  of  tracheal  narrowing. 

The  frequently  associated  pleuritic  effusion  may  complicate  the  difficulties 
of  the  diagnosis  of  mediastinal  disease  as  far  as  physical  signs  are  concerned, 


672  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

but  examination  of  the  fluid  withdrawn  by  the  exploring  needle  is  often  very 
helpful.  The  effusion  is  likely  to  be  blood  tinged  or  somewhat  milky,  due  to 
the  presence  of  fat.  Large  endothelial  cells  in  the  fluid  are  said  to  be  charac- 
teristic of  malignant  tumors  involving  the  pleural  membrane.  Aspiration  of 
the  fluid  of  simple  pleurisy  relieves  the  respiratory  embarrassment  but  when 
a  growth  in  the  mediastinum  exists  this  symptom  persists. 

The  diagnosis  of  the  type  of  the  tumor  may  sometimes  be  made.  Sarcoma 
is  more  likely  to  affect  young  subjects  and  is  usually  more  rapid  in  its  course 
than  carcinoma.    The  latter  may  be  associated  with  growths  in  the  breast. 

2.  Non-malignant  tumors  of  the  mediastinum  such  as  fibromata,  dermoid 
and  hydatid  cysts,  teratomata,  lipomata  and  gummata,  have  been  observed. 

3.  Abscess  of  the  mediastinum  is  not  especially  rare;  it  is  most  common 
in  the  male  sex  and  its  most  frequent  cause  is  traumatism;  the  condition  may 
also  foUow  the  infectious  diseases,  erysipelas  or  tuberculosis.  In  the  latter 
instance  the  course  of  the  affection  is  apt  to  be  chronic.  The  abscess  is  most 
often  situated  in  the  anterior  mediastinum,  is  evidenced  by  a  throbbing  pain 
and,  if  of  large  size,  by  dyspnoea.  In  acute  instances  there  is  an  irregular 
temperature  sometimes  associated  with  rigors  and  sweats.  The  abscess  may 
rupture  through  the  diaphragm,  the  thoracic  wall  or  into  the  trachea,  bronchial 
tubes  or  oesophagus. 

The  condition  may  be  suspected  in  the  presence  of  abscess  of  the  lung, 
empyaema,  or  if,  after  a  history  of  injury  or  caries  of  the  dorsal  vertebrae,  ribs 
or  sternum,  pressure  symptoms  with  septic  temperature  develop.  The  phys- 
ical signs  are  often  indefinite;  a  fluctuating  tumor  may  be  palpable  at  the 
suprasternal  notch  or  behind  the  ensiform  cartilage.  The  employment  of  the 
aspirator  in  doubtful  instances  is  justifiable. 

In  chronic  abscesses  the  pus  may  undergo  cheesy  degeneration,  and  be- 
coming inspissated,  cause  no  evil  result. 

4.  Simple  lymphadenitis  of  the  mediastinal  glands  may  occur  as  a  result  of 
any  inflammatory  condition  of  the  bronchi  and  lungs.  The  glands  are  most 
abundant  in  the  posterior  mediastinum  and  their  involvement  is  characterized 
by  hyperaemia,  infiltration,  swelling  and  oedema.  The  physical  signs  of  the 
condition  consist  of  dulness,  often  very  difficult  to  detect,  between  the  upper 
portions  of  the  scapulas.  In  marked  instances  there  may  be  dulness  over  the 
upper  sternum. 

Tuberculous  affections  of  the  mediastinal  glands  may  be  primary  or  follow 
the  simple  type  of  lymphadenitis. 

5.  Indurative  Mediastino-pericarditis.  This  condition  occurs  in  several 
forms.  It  may  be  characterized  by  pericardial  adhesions  and  marked  increase 
in  the  fibrous  tissues  of  the  mediastinum;  in  a  second  type  the  pericardium  is 
adherent  to  the  neighboring  structures  but  the  mediastinal  inflammation  is 
slight;  in  stifl  another  variety  the  pericardium  may  be  unaffected. 


DISEASE   OF    THE    MEDIASTINUM.  673 

The  condition  is  uncomnion  but  is  most  frequently  observed  in  young 
adults;  it  may  be  associated  with  a  chronic  diffuse  peritonitis.  _  The  symptoms 
are  those  of  pericardial  adhesions  with  cardiac  hypertrophy  and  dilatation; 
dyspnoea,  cyanosis  and  general  oedema  are  usual.  Physical  examination  may 
reveal  the  presence  of  coarse,  dry  r^les  over  the  right  border  of  the  heart. 
These  signs  may  be  more  easily  detected  if  the  patient's  arms  are  raised. 

6.  Mediastinal  Emphysema.  In  traumatism,  fatal  whooping  cough  and 
diphtheria,  and  after  tracheotomy,  air  may  force  entrance  to  the  mediastinum. 
The  occurrence  of  the  condition  is  said  to  be  favored  in  the  latter  instance  by 
the  respiratory  obstruction,  the  forced  effort  at  inspiration  and  the  operative 
division  of  the  deep  cervical  fascia  which,  in  the  proper  performance  of  tra- 
cheotomy, should  not  be  separated  from  the  trachea.  The  emphysema  may 
involve  the  subcutaneous  tissue.  Air  in  the  mediastinum  also  may  be  observed 
in  pneumothorax  and  rupture  of  the  lung. 

The  treatment  of  mediastinal  disease  is  chiefly  symptomatic  although 
operative  interference  in  a  few  instances  has  succeeded  in  removing  tumors 
in  this  situation.  Recovery  is  said  to  take  place  in  40  percent,  of  the  cases 
of  mediastinal  abscess,  but  this  figure  should  be  raised  since  the  statistics 
are  those  of  the  pre-antiseptic  period.  The  treatment  of  abscess  consists  in 
free  incision  and  drainage. 

Favorable  results  have  been  reported  to  have  followed  the  employment 
of  the  Rontgen  ray  in  non-operable  malignant  gro^vths,  but  while  this  form 
of  treatment  is  always  worthy  of  trial,  too  much  should  not  be  expected  of  it. 


43 


/ 


674  DISEASES   OF   THE   URINARY    SYSTEM. 


CHAPTER  IX. 

DISEASES  OF  THE  URINARY  SYSTEM. 

ANOMALIES  OF  THE  KIDNEY. 

Normally  the  kidney,  when  the  body  is  in  the  recumbent  position,  lies  upon 
the  psoas  and  quadratus  lumborum  muscles.  The  organ  of  the  right  side 
is  situated  somewhat  lower — about  f  of  an  inch  (2.0  cm.) — than  that  of  the 
left  owing  to  the  superimposed  liver.  Upon  deep  inspiration  both  kidneys 
descend  slightly,  but  under  normal  conditions,  as  a  rule,  they  cannot  be 
palpated. 

Abnormalities  in  Number. 

Congenital  absence  of  one  or  both  kidneys  may  occur.  In  the  latter  con- 
dition, life  is,  of  course,  impossible,  but  the  former  state  may  exist  unsus- 
pected, unless  the  individual  is  for  some  reason  subjected  to  physical  ex- 
amination and  the  elicitation  of  a  tympanitic  note  over  the  site  of  the  kidney 
and  a  failure  to  detect  its  presence  elsewhere,  leads  to  suspicion  of  the  com- 
plete absence  of  the  organ  with  its  pelvis  and  vireter.  In  certain  instances 
the  remaining  kidney  may  possess  two  pelves  and  ureters.  Rudimentary 
ureters  and  congenital  atrophy  of  one  kidney  are  not  uncommon. 

Abnormalities  of  Size  and  Shape. 

Hypertrophy  of  one  kidney  may  be  observed;  unilateral  atrophy  has  been 
mentioned  above. 

The  lobulated  kidney  is  not  infrequent;  here  the  normal  fcetal  lobulation 
persists,  the  lobes  varying  in  distinctness,  the  fissvu-es  being  in  most  instances 
shallow  but  rarely  so  marked  as  to  separate  the  organ  into  distinct  lobes. 

Union  of  the  two  kidneys  into  a  single  organ  of  horseshoe,  sigmoid  or  dis- 
coidal  form  is  occasionally  met.  The  tissue  joining  the  two  organs  may  be 
fibrous  or  of  true  kidney  structure.  In  the  horseshoe  form  the  junction  is 
usually  at  the  lower  poles  of  the  organs,  more  seldom  is  it  at  the  upper  ends. 
These  abnormally  shaped  kidneys  are,  as  a  rule,  displaced  downward  and 
sometimes  laterally.  They  often  possess  two  pelves  and  at  times  three  or 
four  ureters.     Fused  kidneys  have  been  removed  under  the  impression  that 


THE  MOVABLE  KIDNEY.  675 

they  were  single  displaced  organs.     The   mistake,   as   would  be  expected, 
ends  in.  the  patient's  death  with  anuria. 

THE  MOVABLE  KIDNEY, 

Synonyms.     Floating  Kidney;  Nephroptosis. 

Normally  the  kidney  is  held  in  place  by  the  peri-renal  fatty  tissue,  the  peri- 
tonaeum anterior  to  the  organ  and  the  renal  blood-vessels.  If  for  any  reason 
the  kidney  becomes  displaced  it  may  wander  to  almost  any  part  of  the  abdom- 
inal cavity  or  it  may  be  so  slightly  removed  from  its  normal  position  as  to  be 
very  difficult  of  palpation.  In  the  former  instance  a  fold  of  peritonaeum,  or 
mesonephron,  connects  the  organ  with  the  spinal  column;  certain  clinicians 
would  apply  the  term  -floating  kidney  only  to  this  type  of  the  condition. 

^Etiology.  Movable  kidney  is  far  more  frequent  in  women  than  in  men. 
It  is  predisposed  to  by  hard  muscular  work,  by  tight  lacing  and  by  repeated 
pregnancies  which  cause  a  permanent  relaxation  of  the  abdominal  wall.  One 
woman  in  every  five  of  those  who  have  borne  children  has  a  displaced  kidney, 
much  more  usually  that  of  the  right  side,  although  the  post  mortem  statistics 
are  said  to  be  one  in  fifteen;  this  difference  is  due  to  the  fact  that  when  the 
corpse  is  placed  upon  its  back  the  organ  slips  into  place.  The  displaced  kidney 
is  by  no  means  limited  to  those  who  have  given  birth  to  children  for  it  is  not 
infrequent  in  nulliparae  as  a  result  of  absorption  of  the  peri-renal  fat,  trauma 
or  a  congenital  relaxation  of  the  surrounding  peritonaeal  folds.  The  greater 
frequency  of  displacement  of  the  right  kidney  may  be  due  to  the  presence  of 
the  liver  and  its  pressure  downward  with  each  inspiration. 

Seventy  percent,  of  instances  of  movable  kidney  are  associated  with  ptoses 
of  other  viscera — enteroptosis  or  Glenard's  disease  (see  p.  379) — and  are 
really  a  part  of  the  general  downward  displacement. 

Symptoms.  In  some  instances  the  condition  may  give  rise  to  no  symptoms 
whatever  but,  on  the  other  hand,  there  is  hardly  a  mentionable  symptom  that 
cannot  be  attributed  to  a  movable  kidney.  Reflex  nervous  symptoms  are 
among  the  most  common.  Of  these  indigestion  and  gastric  distiurbances  with 
pain  and  flatulence,  cardiac  palpitation  and  pain,  and  neuralgic  pains  refer- 
red to  any  part  of  the  body,  are  very  frequent.  Gastric  dilatation  may  occur 
and  is  considered  by  some  to  be  a  result  of  the  displacement  of  the  kidney, 
by  others,  to  be  a  cause  of  the  latter  condition.  Constipation  is  very  often 
observed.  Pressure  of  the  displaced  organ  has  been  knov^m  to  cause  appen- 
dicitis. A  dragging  abdominal  pain,  especially  evident  while  standing,  walking 
or  exercising  in  the  erect  position,  is  a  common  symptom,  while  irritability 
of  the  bladder  and  painful  menstruation  are  not  rare. 

Gastric  crises  (Dietl's  crisis)  may  occur  and  are  characterized  by  chills, 
fever,  abdominal  pain,  nausea  and  vomiting  followed  by  a  condition  of  col- 


676  DISEASES    OF    THE    URINARY    SYSTEM. 

lapse;  they  have  been  attributed  to  temporary  occlusion  of  the  renal  vessels 
by  displacement  of  the  kidney  which  twists  these  structures.  During  such 
attacks  the  urine  may  contain  an  excess  of  uric  acid  or  of  oxalates,  or  even 
pus  and  blood,  and  the  organ  itself  may  be  tender. 

Strangulation  of  the  ureter  may  produce  acute  ■  hydronephrosis  of  sudden 
onset  and  equally  sudden  ending. 

The  diagnosis  of  the  condition  is  easily  made  and  in  all  patients  exhibiting 
such  symptoms  as  those  mentioned  above,  the  importance  of  thorough  abdom- 
inal palpation  cannot  be  too  strongly  emphasized.  The  examination  should 
be  conducted  while  the  patient  is  lying  upon  the  back  with  the  knees  drawn 
up  so  as  to  relax  the  abdominal  parietes.  With  the  left  hand  under  the  lumbar 
region  and  the  right  over  the  hypochondrium  just  below  the  costal  margin, 
bimanual  pressure  may  reveal  the  presence  of  a  firm  rounded  body  which  can 
be  slipped  from  between  the  two  hands.  When  impalpable  by  this  method 
a  deep  inspiration  may  bring  the  lower  segment  of  the  organ  into  contact  with 
the  examining  hand.  The  kidney  is  only  slightly,  if  at  all,  sensitive  to  pressure 
of  ordinary  force;  pronounced  pressure  may  cause  a  characteristic  sickening 
pain.  The  normally  placed  organ  is  not  palpable  except  under  extraordinary 
circumstances.  Examination  posteriorly  may  show  a  flattening  over  the 
normal  site  of  the  kidney  and  a  more  resonant  percussion  note  than  that  upon 
the  other  side.  The  patient  may  be  subjected  to  palpation  similar  to  that 
described  above  while  in  the  erect  position. 

Treatment  consists  in  the  employment  of  all  means  calciilated  to  restore 
the  patient's  general  health  (see  the  section  upon  the  treatment  of  neuras- 
thenia). Thin  patients  in  whom  the  peri-renal  fat  has  been  absorbed  should 
be  put  to  bed  with  the  foot  of  the  couch  elevated  six  to  eight  inches  so 
that  we  may  have  the  aid  of  gravity  in  keeping  the  kidney  in  place  after  it 
has  been  restored  by  manipulation.  The  diet  should  be  very  nourishing 
and  should  contain  a  large  amount  of  milk — at  least  two  quarts  (litres)  daily 
— the  object  being  to  restore  the  retroperitonaeal  fat.  If  there  is  associated 
enteroptosis  the  diet  should  be  that  of  gastric  dilatation,  frequent  small 
meals  of  dry  food,  preferably  peptonized.  The  thirst  may  be  controlled 
by  giving  a  quart  (litre)  of  saline  solution  per  rectum  every  three  or  four 
hours.  Fat  inunctions,  for  instance  a  mixture  of  codliver  oil,  one  part 
to  lanolin  seven  parts,  should  be  employed.  Cocoa  butter  and  other 
vegetable  fats  may  also  be  used.  The  treatment  should  be  continued  for 
at  least  six  weeks.  Stout  patients  should  wear  a  properly  fitting  bandage 
and  pad  so  constructed  as  to  hold  the  kidney  in  place;  where  this  is  unob- 
tainable an  ordinary  long  "straight-front"  corset  laced  tightly  below  and 
loosely  at  the  top  may  often  be  worn  with  benefit.  Strapping  the  abdomen 
with  adhesive  plaster  so  applied  as  to  hold  the  kidney  in  place,  is  also  to  be 
recommended.     All  the  above  appliances  should  be  put  on  while  the  patient 


ALBUMINURIA.  677 

is  either  lying  on  the  back  with  the  hips  elevated  or  is  in  the  knee  chest  position. 
The  administration  of  physostigmine  salicylate  in  doses  of  j^-^  of  a  grain 
(0.0006)  twice  daily  is  very  advantageous;  it  is  a  most  potent  means  of  relieving 
the  constipation  and,  where  there  is  associated  enteroptosis,  it  tends  to  correct 
this  latter  by  stimulating  the  smooth  muscle  fibre  of  the  digestive  tract.  Elec- 
tricity is  of  comparatively  little  use  as  a  stimulant  to  the  musculature  of  the 
stomach  and  intestines,  but  may  be  employed.  Massage  is  much  more  effica- 
cious. The  pain  and  other  symptoms  associated  with  Dietl's  crises  necessitate 
the  application  of  heat  to  the  abdomen  and  the  hypodermatic  administration 
of  morphine. 

Surgical  treatment  has  been  much  vaunted  as  a  means  of  cure  in  movable 
kidney  and  is  certainly  useful  in  properly  selected  instances.  It  consists  in 
sewing  the  organ  into  its  proper  place  and  is  followed  by  disappearance  of 
the  symptoms  only  when  the  neplaroptosis  is  not  a  part  of  a  general  viscerop- 
tosis; here  it  is  useless.  The  congested  kidney  should  never  be  operated  upon 
and  the  kidney  which  is  the  seat  of  pain  (neuralgia)  is  not  a  proper  subject 
for  nephropexy  for  the  pain  will  be  increased  by  the  procedure.  In  conclusion 
it  may  be  said  that  anchoring  the  kidney  when  nephroptosis  alone  is  present, 
may  achieve  a  brilliant  result  but  only  under  the  conditions  cited  above. 
Faulty  technique,  however,  may  result  disastrously,  for  multiple  abscesses 
of  the  kidney,  pyelonephrosis  and  psoas  abscess  have  been  known  to  follow 
the  employment  of  contaminated  ligatures.  Nephrectomy  is  to  be  advised 
in  grave  cases  only,  and  in  these  never  except  after  the  failure  of  other  methods 
of  treatment. 

ALBUMINURIA. 

Definition.  Any  condition  characterized  by  presence  of  albumin  in  the 
urine. 

Two  main  forms  of  the  affection  are  recognized:  a.  Those  associated  with 
distinct  lesions  of  the  kidney  or  other  portions  of  the  urinary  tract,  b.  Those 
in  which  such  lesions  are  wanting. 

In  the  former  class  we  may  make  the  following  subdivisions:  i.  Renal 
albuminuria  due  to  congestion  of  the  kidneys  in  its  various  forms.  2.  Organic 
lesions  of  the  kidneys  such  as  acute  and  chronic  nephritis,  degenerations, 
suppuration  and  neoplasms  of  the  organs.  3.  Suppurative  conditions  of 
the  pelves  of  the  kidneys,  the  ureters,  the  bladder  or  of  the  urethra. 

Of  the  forms  of  albuminuria  occurring  in  the  absence  of  definite  renal 
lesions  the  most  frequent  is  that  which  so  often  appears  during  the  course  of 
the  infectious  diseases,  the  so-called  febrile  albuminuria.  Here  the  albumin 
results  from  slight  alterations  in  the  glomeruli  brought  about  either  by  the 
rise  in  temperature  or  by  the  excretion  of  the  toxins  of  the  disease  through 


678  DISEASES    OF    THE    URINARY    SYSTEM. 

the  kidneys.  The  albumin  is  usually  smaU  in  amount,  may  be  accompanied 
by  hyaline  or  epithelial  casts  and  disappears  as  the  patient's  condition 
becomes  ameliorated. 

Functional  or  physiological  albuminuria  is  observed  in  certain  subjects 
after  violent  exertion,  cold  bathing,  over-eating — especially  of  nitrogenous  food 
— mental  emotion,  etc.  It  may  occur  intermittently  in  poorly  nourished  chil- 
dren, especially  those  of  neurotic  heredity.  In  some  instances  it  appears  during 
the  period  of  the  onset  of  puberty,  in  others  the  albumin  is  present  in  the  urine 
from  time  to  time  all  through  the  life  of  the  individual.  When  it  is  observed 
at  regular  intervals  it  is  termed  cyclic  alhuminuria.  Orthostatic  or  postural 
albuminuria  is  still  another  type  of  the  so-called  physiological  albuminuria 
and  seems  to  occvu:  as  a  result  of  the  maintenance  of  an  upright  position  of 
the  body,  at  any  rate  its  quantity  appears  to  depend  upon  the  amount  of  time 
spent  in  a  standing  posture.  Usually  in  all  varieties  of  functional  albuminuria 
the  quantity  of  the  albumin  is  small,  although  at  times  large  amounts  are 
present.  The  quantity  of  the  urine  and  its  specific  gravity  remain  normal 
but  occasionally  a  few  hyaline  casts  are  found.  The  cause  of  the  albuminuria 
is  probably  some  slight  change  in  the  renal  epithelium  due  to  the  influence 
of  some  irritant;  in  other  instances  some  circulatory  disturbance  may  be 
the  causative  factor  although  an  increased  tension  of  the  pulse  and  an  accen- 
tuated second  aortic  sound  may  be  absent. 

In  many  subjects  the  albuminuria  persists  without  other  symptoms  for 
varying  lengths  of  time  and  finally  complete  recovery  ensues;  in  other  indi- 
viduals the  albuminuria  continues  to  occur  at  intervals,  casts  are  present, 
there  is  arterial  hypertension,  the  second  aortic  sound  is  increased  in  intensity 
and  a  true  nephritis  gradually  makes  its  appearance. 

Alhuminuria  due  to  disorders  of  the  blood.  In  pregnancy  albuminuria 
is  frequently  present  and  is  usually  due  to  some  circulatory  disturbance,  although 
certain  instances  may  be  attributed  to  metabolic  abnormalities;  usually, 
however,  there  are  changes  in  the  kidneys  in  the  albuminuria  of  pregnancy 
and  casts  are  frequently  to  be  found. 

In  anaemia,  leukaemia,  scorbutus,  purpuric  conditions,  as  well  as  in  lead, 
mercury  and  syphilitic  poisoning,  albumin  may  occur  in  the  urine  as  a  result 
of  the  toxaemia. 

Hyperglycaemia  and  cholaemia  may  be  associated  with  the  presence 
of  albuminuria  and,  as  a  result  of  the  excretion  of  inhaled  chloroform  or 
aether  vapor,  the  urine  after  anaesthesia  may  contain  albumin  in  small 
quantities. 

In  certain  abnormal  conditions  of  the  nervous  system  albuminuria  may 
occur,  notably  in  epilepsy,  cerebral  haemorrhage,  meningitis,  tetanus,  cephalic 
injuries  and  in  exophthalmic  goitre. 


ACUTE    CONGESTION    OF    THE    KIDNEY.  679 

ACUTE  CONGESTION  OF  THE  KIDNEY. 

Synonym.     Active  Hyperaemia  of  the  Kidney. 

Definition.  An  acute  transient  engorgement  of  the  blood-vessels  of  the 
kidney. 

.Etiology.  This  condition  is  caused  by  the  presence  of  irritant  substances 
in  the  blood  current,  such  as  result  from  acute  poisoning  by  certain  drugs, 
notably,  cantharides,  copaiba,  turpentine,  cubebs,  squill,  phenol,  creosote, 
arsenic,  etc.  It  occurs  also  as  the  first  stage  of  acute  nephritis  and 
probably  also  as  a  result  of  the  presence  in  the  organism  of  the  toxins  of  the 
acute  infectious  diseases,  although  the  researches  of  Mendelsohn  have  shown 
that  the  kidney  of  febrile  disease  is  small  and  pale.  Acute  congestion  also 
takes  place  in  the  remaining  kidney  after  nephrectomy. 

Pathology.  The  organ  is  swollen,  hyperaemic  and  darker  than  normal  in 
color;  cut  section  shows  a  wider  and  darker  cortex  than  the  normal;  the  medulla 
is  less  red  than  normal  and  the  line  of  demarcation  between  it  and  the 
cortex  is  indistinct.  Microscopically  the  Malpighian  bodies  are  swollen 
and  their  epithelial  lining  is  the  seat  of  cloudy  swelling. 

Symptoms.  There  may  be  lumbar  pain  and  slight  fever  and  acceleration 
of  the  pulse.  The  urine  is  scanty  in  quantity  and  in  marked  instances  it  may 
be  suppressed.  Its  color  is  dark,  its  specific  gravity  high  and  albuminuria 
in  greater  or  less  degree,  with  a  few  hyaline  and  granular  casts  and  perhaps 
a  small  number  of  red  blood  cells,  is  present.  Dropsy  and  uraemic  symptoms 
are  absent. 

The  prognosis  is  favorable  although  repeated  attacks  may  bring  about  an 
acute  nephritis. 

Treatment  consists  in  confinement  to  bed  and  the  limitation  of  the  diet 
to  milk.  The  congestion  itself  may  be  lessened  by  the  application  of  dry 
cups  and  hot  poultices  to  the  lumbar  region  and  especially  by  the  administra- 
tion of  high  rectal  irrigations  of  hot  (116°  to  120°  F. — 46.5°  to  4B.8°C.)  normal 
saline  solution  in  quantity  of  i  to  2  gallons  (4  to  8  litres).  These  may  be 
repeated  several  times  a  day  and  cause  a  rapid  and  marked  increase  in  the 
amount  of  the  urine  and  a  diminution  of  the  albumin.  Hot  packs  are  also 
useful;  the  bowels  should  be  kept  freely  open  by  means  of  salines,  and  water 
may  be  freely  drunk. 

CHRONIC  CONGESTION  OF  THE  KIDNEY. 

Synonyms.  Passive  Hyperaemia  of  the  Kidney;  Mechanical  Hyperaemia 
of  the  Kidney;  Passive  Congestion  of  the  Kidney. 

Definition.  A  chronic  venous  engorgement  of  the  blood-vessels  of  the 
kidney. 

.Etiology.     This  condition  results  from  chronic  disease  of  the  heart,  lungs 


68o  DISEASES    OF    THE    URINARY    SYSTEM. 

or  liver,  which  is  associated  with  obstruction  to  the  circulation  and  is  in  such 
instances,  a  part  of  a  systemic  venous  congestion.  Chronic  renal  congestion 
may  also  be  due  to  tumors,  the  pregnant  uterus  or  collections  of  ascitic  fluid 
pressing  upon  the  renal  veins;  more  rarely  is  the  condition  caused  by  throm- 
bosis of  these  vessels  or  of  the  ascending  vena  cava. 

Pathology.  The  kidneys  are  enlarged  and  firm  and  the  capsule  is  non- 
adherent. Cross  section  shows  the  medulla  to  be  darker  red  than  the  cortex; 
the  substance  is  firm  and  resistant  and  is  coarse  in  appearance.  The  connec- 
tive tissue  of  the  organ  is  increased,  the  walls  of  the  capillaries  are  thickened  and 
their  lumen  is  dilated;  the  tubal  epithelium  may  be  the  seat  of  granular,  fatty 
or  hyaline  degeneration.     Sclerosis  of  the  Malpighian  bodies  sometimes  occurs. 

Symptoms.  Associated  with  those  of  the  primary  disease  of  which  the 
renal  congestion  is  the  result,  general  dropsy  is  a  prominent  manifestation. 
It  is  first  noticed  in  the  feet  and  ankles  whence  it  may  ascend  to  the  abdomen, 
the  pleural  cavities  and  the  upper  extremities.  The  urine  is  diminished  in 
quantity,  dark  in  color  and  of  high  specific  gravity.  Albumin  is  present  in 
variable  amount  and  with  it  may  be  associated  hyaline  casts,  blood  cells  and 
desquamated  tubal  epithelium.  The  solids  excreted  by  the  urine  are  present 
in  normal  quantity.  Uraemia  in  uncomplicated  clironic  renal  congestion  is 
a  very  rare  occurrence. 

The  diagnosis  is  sometimes  doubtful,  the  condition  being  often  difficult  of 
differentiation  from  clironic  nephritis.  Points  which  may  aid  in  separation  of 
the  two  conditions  are  the  normal  excretion  of  urea,  infrequency  of  uraemia, 
less  dropsy  and  albuminuria,  and  smaller  number  of  casts,  which  are  features 
of  chronic  renal  congestion. 

The  prognosis  is  that  of  the  primary  disease;  a  chronic  nephritis  may  result 
in  a  certain  number  of  instances.  Proper  treatment  may  succeed  in  restoring 
the  normal  function  of  the  kidney. 

Treatment  consists  primarily  in  the  proper  management  of  the  causal 
lesion  (see  the  treatment  of  chronic  endocarditis,  hepatic  cirrhosis,  pulmonary 
diseases,  etc.).  The  patient's  general  condition  should  receive  attention,  and 
rest,  a  light  and  easily  digestible  diet,  and  proper  hygienic  surroundings  should 
be  insisted  upon  by  the  physician.  Iron,  arsenic  and  strychnine  are  useful 
tonics.  Digitalis  and  its  substitutes  (see  p.  591)  will  usually  increase  the 
excretion  of  urine  and  may  cause  a  disappearance  of  the  albumin  and  casts 
and  of  the  other  distressing  symptoms.  Depletion  through  the  intestinal 
tract  should  not  be  forgotten;  here  the  hydrogogue  cathartics,  especially  the 
salines,  are  indicated  and  the  high  rectal  saline  irrigation  as  described  under 
the  section  upon  the  treatment  of  acute  renal  congestion  is  a  very  valuable 
adjuvant  to  the  treatment.  The  dropsical  condition  may  be  lessened  by 
prescribing  a  diet  in  which  the  chlorides  are  limited  (see  p.  694).  Large 
pleural  or  abdominal  collections  of  fluid  should  be  withdrawn  by  aspiration. 


UILaEMIA.  681 


UREMIA. 


Definition.  A  condition  attributed  to  inadequacy  of  the  renal  function, 
occurring  as  a  result  of  retention  of  the  substances  which  normally  are  excreted 
through  the  kidneys,  and  often  appearing  in  connection  with  nephritis  and 
other  states  in  which  the  urinary  excretion  is  deficient  or  suppressed.  There 
are,  however,  doubts  to  be  cast  upon  this  theory  of  the  production  of  urasmia, 
for  complete  anuria  does  not  always  result  in  the  appearance  of  this  condition 
nor  is  there,  in  uraemic  subjects,  a  constant  increase  of  the  urea  in  the  blood 
or  a  concurrent  diminution  of  the  excrementitious  solids  of  the  urine.  Many 
instances  of  uraemia  are  unaccompanied  by  an  excess  of  nitrogenous  excre- 
mentitious products  in  the  blood,  these  substances  have  even  been  found  in 
abnormally  small  quantities  during  uraemic  attacks,  and  the  ursemic  syndrome, 
on  the  other  hand,  is  often  absent  when  the  blood  contains  these  supposedly 
toxic  products  in  abnormally  large  amount. 

It  has  also  been  determined  that  uraemia  may  occur  when  the  nitrogen  taken 
into  the  body  is  equivalent  to  that  excreted,  when  less  of  the  nitrogenous 
substances  are  cast  off  than  are  taken  in  and  even  when  the  output  of  nitrogen 
is  far  in  excess  of  the  intake;  likewise,  as  above  stated,  uraemia  may  not  develop 
when  the  retention  of  nitrogen  is  abnormally  large.  It  would  seem,  therefore, 
that  nitrogen  retention,  alone,  has  little  to  do  with  the  causation  of  uraemia. 
The  theory  has  recently  been  promulgated  that  the  liver  may  be  responsible 
for  its  development  and  that  the  diminished  urea  excretion  is  due  to  the  fact 
that  little  is  being  formed  within  the  body  rather  than  that  that  already  formed 
is  being  retained.  This  hypothesis  is  favored  by  the  fact  that  frequently 
when  the  urea  in  the  blood  and  urine  is  diminished,  there  is  a  corresponding 
augmentation  in  the  amount  of  ammonia  in  these  fluids.  This  would  seem 
to  point  to  the  liver  as  the  organ  at  fault,  for  it  is  here  that,  under  normal 
conditions,  most  of  the  ammonia  in  the  blood  is  changed  into  vu^ea.  In  addi- 
tion, the  relative  increase  in  the  excretion  of  the  purin  bodies,  which  normally 
are  changed  in  the  liver  to  uric  acid,  over  that  of  the  latter  substance,  the 
relative  increase  in  the  uric  acid  excretion,  this  substance  normally  being  con- 
verted into  urea  also  in  the  liver,  over  that  of  urea,  the  occurrence  of  glycur- 
onates,  amido-acid  compounds  and  of  acetones,  puts  further  onus  upon  the 
liver.  Although  we  have  much  to  learn  concerning  the  metabolic  functions 
of  the  liver,  it  may  not  be  unfair  to  suppose  that  given  an  affection  of  the 
kidneys  which  interferes  with  their  normal  excretory  power,  the  poisons  with 
which  these  organs  shovild,  under  ordinary  conditions,  cope  are  thrust  upon  the 
liver  with  the  result  that  sooner  or  later,  depending  upon  the  organ's  power  of 
resistance,  upon  the  concentration  of  the  toxic  substances  and  upon  the  length 
of  the  period  during  which  they  are  present,  the  organ  becomes  insufficient. 

Another  theory  which  also  lays  the  responsibility  for  the  incidence  of  uraemia 


682  DISEASES    OF    THE    URINARY    SYSTEM. 

upon  the  liver  is  that  the  normal  kidney  acts  as  a  filter,  and  when  diseased,  this 
function  becomes  so  altered  that  substances  which  formerly  easily  passed 
through  the  organ  are  now  retained,  while  others,  previously  retained,  are  now 
excreted;  among  these  last,  elements  may  exist  which  are  useful  in  the  chemistry 
of  the  body  and  under  normal  conditions  would  have  been  further  oxydized. 
Such  substances  are  various  derivatives  of  albumin.  These  being  lost  to  the 
body,  the  organism  must  disintegrate  more  albumin  in  order  to  supply  the 
lack,  and  this  extra  labor  involves  the  liver  again  which  ultimately  becomes 
worn  out,  a  condition  of  hepatic  insufficiency  supervening.  It  is  probable, 
however,  that  the  liver  alone  is  not  to  be  held  responsible  for  the  development 
of  urasmia  but  that  the  condition  really  is  the  result  of  a  general  disturbance 
of  metabolism. 

Symptoms.     These  may  be  considered  under  several  heads. 

a.  Those  referable  to  the  nervous  system.  One  of  the  earliest  of  these 
is  drowsiness  which  may  appear  suddenly  or  gradually;  with  it  vertigo  and 
headache,  frequently  in  the  occiput,  are  often  present.  The  drowsiness  may 
go  on  to  coma,  at  times  so  marked  that  there  is  no  response  upon  the  part 
of  the  patient  to  a  stimulus.  Epileptiform  convulsions  may  alternate  with 
the  coma,  immediately  follow  the  lethargy,  without  the  intervention  of  coma, 
or  appear  independently  and  without  warning.  The  convulsive  movements 
vary  from  slight  twitching  to  a  paroxysm  similar  to  that  of  a  violent  epileptiform 
seizure;  the  temperature  is  usually  subnormal  but  sometimes  a  febrile  move- 
ment is  present.  Acute  mania  and  insanity  with  delusions  are  not  infre- 
quent; melancholia  and  various  paralyses,  hemiplegia  or  monoplegia,  may 
be  observed.  The  palsies  may  follow  a  convulsive  attack  or  appear  independ- 
ently; no  gross  changes  may  be  found  at  autopsy,  but  localized  oedema  of  the 
brain  may  be  present  here  and  after  death  in  convulsions  or  coma.  Sudden 
blindness  (uraemic  amaurosis)  may  usher  in  a  ursemic  seizure  or  appear  after 
a  convulsion.  It  is  usually  transient,  lasting  but  a  few  days;  retinal  changes 
are  seldom  seen.     Uraemic  deafness  has  been  noted  but  is  infrequent. 

Pruritus  is  not  rare  and  may  be  due  to  the  elimination  of  toxic  products 
through  the  skin;  with  it  an  erythema  may  be  present  accompanied  by  a  frosty 
coating  of  urea  crystals  upon  the  skin. 

Numbness  and  tingling  of  the  extremities  and  muscular  cramps,  especially 
at  night  and  in  the  calves  of  the  legs,  are  less  typical  symptoms. 

Respiratory  Symptojns.  Uraemic  dyspnoea  is  common.  It  often  appears 
suddenly  at  night,  the  attack  markedly  resembling  that  of  true  asthma,  respi- 
ration being  impossible  while  in  the  recumbent  position.  Dyspnoea  due  to 
cardiac  dilatation  and  to  pulmonary  oedema  may  be  associated  with  uraemia. 
In  other  instances  the  dyspnoea  is  continuous  and  in  still  others  Cheyne-Stokes 
respiration  may  be  present  and  persistent  for  considerable  periods  of  time 
even  when  unassociated  with  coma. 


UREMIA.  683 

Gastro-intestinal  symptoms  may  be  the  first  manifestations  of  uraemia  and 
include  anorexia,  nausea  and  persistent  vomiting;  with  these  diarrhcea  may 
be  associated  or  the  last  may  occur  independently,  being  due  to  catarrhal 
or  diphtheritic  colitis.  The  tongue  is  frequently  covered  with  a  thick  coating, 
the  breath  is  foul  and  a  stomatitis  with  swelling  of  the  buccal,  gingival  and 
lingual  mucous  membranes  may  be  observed. 

Suppression  of  urine  is  often  the  first  symptom  but  is  not  an  essential  one. 
It  may  be  associated  with  a  urinous  odor  of  the  breath,  sweat  and  also  of 
the  vomitus,  if  emesis  is  present. 

A  rise  of  temperature  is  a  frequent  symptom  but  is  by  no  means  always 
noted. 

The  diagnosis  of  uraemia  by  means  of  the  estimation  of  the  amount  of  urea 
in  the  blood  is  somewhat  uncertain  for,  as  previously  stated,  the  condition 
may  not  develop  when  the  urea  content  of  the  blood  is  much  increased  and 
it  may  appear  when  the  urea  is  present  in  abnormally  small  quantity.  The 
examination  of  the  blood  and  urine  by  means  of  cryoscopic  and  electric 
conductivity  tests  with  the  hope  of  being  able  to  anticipate  a  uraemic  attack, 
is  more  or  less  futile  for  it  has  been  shown  that  uraemia  often  develops 
when  the  salt  values  in  the  blood  are  normal  or  subnormal,  and  that  uraemia 
is  by  no  means  certain  to  appear  when  there  is  a  marked  augmentation  of 
the  salts  in  the  blood  and  corresponding  decrease  in  those  of  the  urine.  The 
quantitative  determination  of  the  urea  excretion  in  the  urine  is  of  little  value 
in  predicting  a  uraemic  paroxysm. 

With  a  regard  to  the  differential  diagnosis  of  uraemic  coma  it  may  be  said 
that  a  sudden  attack  of  coma  attended  with  diminished  urine  of  abnormally 
low  urea  content  is  likely  to  be  of  uraemic  origin.  The  coma  of  alcoholism 
or  of  opium  poisoning  may  be  mistaken  for  that  of  uraemia  but  in  the  former 
the  pupils  are  dilated,  in  the  second  they  are  contracted  while  in  the  last  con- 
dition they  may  be  either  the  one  or  the  other. 

The  prognosis.  The  occurrence  of  urcemia  is  always  an  unfavorable 
manifestation  but  is  by  no  means  always  a  fatal  one. 

Treatment.  The  treatment  of  the  uraemic  seizure  will  be  dealt  with  in  the 
sections  devoted  to  the  treatment  of  the  nephritides  and,  in  addition  to  the 
methods  there  suggested,  the  injection,  after  venesection,  of  a  solution  of  sodium 
chloride  (0.9  percent.)  containing  sodium  bicarbonate  or  a  solution  of  sodium 
citrate  or  phosphate  may  be  advisable;  an  important  consideration,  however, 
is  the  prevention  of  the  development  of  the  acute  paroxysm.  This  is  to  be 
accomplished  by  giving  studious  attention  to  the  condition  of  the  functions 
of  the  organs  at  fault,  particularly  the  liver.  Stimulation  of  this  organ  is 
contraindicated  in  the  pre-uraemic  state;  on  the  contrary,  rest  is  a  paramount 
consideration.  The  over-worked  liver  should  be  spared  as  much  as  possible 
and  likewise  the  general  metabolism  of  the  body  should  be  regulated.     The 


684  DISEASES    OF    THE    URINARY    SYSTEM. 

liver  is  given  a  period  of  rest  by  the  elimination  from  the  diet  of  substances 
which  are  in  the  least  irritative  or  stimulative,  that  is  to  say  the  patient  should 
be  put  to  bed  and  upon  a  regimen  chiefly  of  milk,  gruels  and  easily  digesti- 
ble semi-solids.  This  should  be  continued  for  a  considerable  period  and  at  the 
same  time  elimination  of  the  accumulated  toxins  is  assisted  by  means  of  high 
rectal  irrigations  of  hot  normal  saline  solution.  These  should  be  given  twice 
daily  and  should  consist  of  two  gallons  (eight  Htres)  of  the  solution  at  from 
ii6°  to  120°  F.  (46.5°  to  49°  C.)  administered  by  means  of  a  fountain  syringe 
suspended  from  three  to  four  feet  above  the  patient  and  to  which  a  soft  rubber 
rectal  tube  is  attached.  When  the  liver  has  been  thoroughly  rested  it  should 
be  stimulated  to  undertake  its  work  once  more  by  means  of  moderate  doses  of 
salicylic  acid,  sodium  oleate,  or  if  necessary,  small  doses  of  calomel.  A  pill 
consisting  of  2  grains  (0.13)  of  acid  sodium  oleate,  2  grains  (0.13)  of  phenol- 
phthalein,  5  grains  (0.33)  of  methyl  salicylate,  and  I  grain  (0.016)  of  menthol 
will  be  found  very  useful.  Of  these  four  to  eight  pills  may  be  given  during 
the  twenty-four  hours,  and  through  their  influence  the  bile  becomes  more 
fluid,  any  tendency  to  hepatic  hyperaemia  is  corrected  and  intestinal  fermen- 
tation is  to  some  extent  prevented.  While  this  treatment  is  being  carried  on 
the  condition  of  the  liver  function,  as  evidenced  by  the  patient's  general  state, 
and  the  composition  of  the  faeces  and  urine,  must  be  watched. 

ACUTE  NEPHRITIS. 

Synonyms.  Acute  Bright's  Disease;  Acute  Desquamative  Nephritis; 
Acute  Diffuse  Nephritis;  Acute  Catarrhal  Nephritis. 

Definition.  An  acute  inflammation  of  the  kidneys  involving  the  epithelial, 
vascular  and  connective  tissues  of  these  organs.  The  degree  to  which  these 
various  structures  are  affected  differs  in  different  instances. 

iEtiology.  Acute  nephritis  occurs  most  frequently  as  a  result  of  one  of 
the  acute  infectious  diseases,  scarlatina,  diphtheria  and  smallpox  being  especi- 
ally prone  to  be  followed  by  this  complication.  The  inflammation  is  observed 
less  frequently  in  measles,  enteric  fever,  cholera,  yellow  fever  and  dysentery, 
and  is  still  more  rare  in  acute  articular  rheumatism,  tonsillitis,  syphilis,  acute 
tuberculosis  and  malaria.  It  may  be  observed  in  septicaemia,  pyaemia  and 
purpuric  conditions.  Exposure  to  cold  and  wet  is  a  not  uncommon  cause;  the 
acute  congestion  caused  by  the  ingestion  of  chemical  poisons  such  as  potassium 
chlorate,  phenol,  mercury,  arsenic,  creosote,  etc.,  may  go  on  to  acute  nephritis; 
it  may  also  occur  secondarily  to  operations  upon  the  kidney.  Chronic  skin 
diseases  and  burns,  in  the  latter  instance  probably  as  a  result  of  toxins  absorbed 
through  the  burned  surface  or  of  poisonous  substances  developed  in  the  organ- 
ism, may  be  accompanied  by  acute  kidney  inflammation. 

The  condition  is  often  seen  in  pregnancy  and  is  now  considered  to  be  a 


ACUTE    NEPHRITIS.  685 

part  of  a  general  toxaemia  rather  than  the  result  of  pressure  upon  the  renal 
vessels. 

Acute  nephritis,  since  the  acute  exanthemata  and  other  infectious  diseases 
are  frequent  in  childhood,  often  is  seen  in  the  young.  It  is  rare  after  middle 
life  but  may  occur  in  adults  before  this  period  has  been  reached,  depending 
in  its  frequency  upon  the  incidence  of  its  various  causes. 

Pathology.  Both  organs  are  equally  affected  and  while  in  the  milder  types 
of  the  inflammation  they  may  exhibit  no  appreciable  gross  change,  in  the 
severer  forms  they  are  more  or  less  enlarged,  sometimes  even  to  twice  their 
normal  size  and  weight.  The  capsule  is  easily  stripped  off,  the  kidney  sub- 
stance is  less  firm  than  normal  and  its  surface  is  smooth,  mottled  and  may  pre- 
sent hasmorrhagic  spots.  Upon  section  the  cortex  appears  swollen  and  reddish 
and  the  inter-pyramidal  portions  of  the  medulla  are  also  enlarged;  from  the 
cut  surface  dark  blood  oozes  in  considerable  amount;  this  being  removed  the 
blood-vessels  are  seen  to  be  congested  and  between  them  pale  areas  may  be 
detected.  The  Malpighian  bodies  may  be  swoUen,  dark  and  congested;  in 
other  instances  they  are  pale. 

Microscopically,  changes  in  the  tubules,  in  the  glomeruli  and  in  the  inter- 
stitial tissue  may  be  found.  The  tubal  epithehum  is  swollen  and  may  be  the 
seat  of  fatty  or  hyaline  degeneration.  The  convoluted  tubules  may  contain 
desquamated  epithelial  cells,  leucocytes  and  red  corpuscles  and  even  hyaline 
or  blood  casts.  The  epithehum  of  the  straight  tubes  is  not  affected  but  their 
lumens  may  be  blocked  by  cells  and  degenerated  matter  which  also  may 
be  found  in  the  convoluted  tubules. 

The  toxic  cause  of  the  nephritis  affects  the  glomeruli  earlier  than  the  other 
portions  of  the  kidney  structure;  their  capillaries  are  distended  with  blood  and 
their  walls  are  often  the  seat  of  a  hyaline  degeneration;  the  epithelium  of  the 
glomeruli  and  of  Bowman's  capsule  may  be  involved  and  the  cavity  of  the 
latter  may  be  distended  with  leucocytes  and  red  blood  cells.  The  connective 
tissue  about  the  capsule  may  be  increased  and  this,  with  the  other  changes,  may 
affect  the  nutrition  of  the  tubules  to  a  marked  extent 

In  mild  instances  of  the  disease  the  interstitial  tissue  is  the  seat  of  an  exuda- 
tion of  serum  and  an  extravasation  of  red  and  white  blood  cells;  in  the  more 
marked  inflammations  the  cells  are  greater  in  number  and  there  is  often  an 
infiltration  of  small  cells  between  the  convoluted  tubules  and  about  the  cap- 
sules. These  changes  may  be  localized  in  certain  parts  of  the  organ  or  gen- 
erally scattered  through  its  tissue 

Symptoms.  The  onset  of  the  disease  may  be  sudden,  especially  in  the  type 
which  follows  exposure,  or  it  may  be  gradual.  The  first  manifestation  is  a 
pufl&ness  under  the  eyes  or  cedema  of  the  ankles.  Rarely  is  the  inflammation 
ushered  in  by  a  chill  but  its  invasion  may  be  marked  by  a  convulsion  in  children. 
Nausea,  vomiting  and  lumbar  pain  are  frequent  symptoms.     The  tempera- 


686  DISEASES    OF    THE    URINARY    SYSTEM. 

ture  is  seldom  high  and  in  certain  instances  fever  may  be  wholly  absent  unless 
it  occurs  as  a  symptom  of  the  causative  disease.  The  pulse  may  be  slightly 
accelerated  but  an  increase  in  tension  is  very  constantly  present  and  there  is 
consequent  accentuation  of  the  second  aortic  sound. 

Svi^eating  is  diminished  and  the  urine  is  scant  in  quantity;  entire  suppres- 
sion may  occur  as  an  early  symptom.  With  the  diminution  of  the  urine  there 
is  usually  dropsy,  although  this  symptom  may  at  times  be  absent.  The  oedema 
begins  about  the  face  and  in  the  ankles,  v^^hence  it  extends  to  the  trunk  and 
upper  limbs.  It  often  involves  the  scrotum  and  prepuce  as  well  as  the  pcri- 
tonaeal  and  pleural  cavities.     (Edema  of  the  lungs  or  glottis  may  occur. 

Anaemia  is  very  constant  and  there  may  be  haemorrhages  from  the  nose  and 
into  the  skin  during  the  disease. 

The  urine  is  very  characteristic;  it  is  scanty,  perhaps  but  a  few  ounces  in 
the  twenty-four  hours,  high  colored  and  of  high  specific  gravity;  its  acidity  may 
be  increased  and  the  sediment  is  often  profuse,  amorphous  and  reddish  brown 
in  color.  Chemical  examination  reveals  the  presence  of  a  considerable  quan- 
tity of  albumin,  the  urine  often  becoming  almost  entirely  solid  upon  boiling; 
the  albumin  may  be  estimated  to  be  50  percent,  or  more  by  volume;  by  weight 
it  is  rarely  over  2  percent.  The  albumin  is  made  up  of  that  contained  in  the 
extravasated  blood  and  of  the  products  of  the  degeneration  of  the  lining  of 
the  tubules.  The  urea,  while  of  high  percentage,  is  considerably  diminished  in 
twenty-four  hour  amount.  The  microscope  shows  the  sediment  to  be  composed 
of  blood  cells,  desquamated  epithelium  and  casts  of  the  uriniferous  tubules; 
the  latter  are  hyaline  and  granular  for  the  most  part,  but  casts  to  which 
blood  cells  or  epithelium  in  various  stages  of  degeneration,  are  attached,  are 
common;  these  latter  are  rather  characteristic  of  acute  nephritis. 

Uraemic  symptoms  (see  p.  682)  may  appear  at  any  time  and  add  to  the 
gravity  of  the  disease;  they  are  usually  a  late  manifestation  but  may  occur 
with  the  suppression  of  urine  which  marks  the  onset. 

Retinal  haemorrhages  have  been  observed  but  ocular  involvement  is  not 
very  common. 

The  course  of  acute  nephritis  varies;  it  may  last  but  a  few  days  or  be  pro- 
longed for  weeks;  the  kidneys  may  return  to  their  normal  condition  or  the 
disease  may  pass  into  the  chronic  type  of  the  affection. 

Complications  are  few  but  among  those  liable  to  occur  may  be  mentioned 
pneumonia  and  empyaema  resulting  from  an  infection  of  the  pleural  transudate. 

The  diagnosis,  in  instances  of  well-marked  symptoms,  is  easy,  especially 
if  we  have  the  history  of  a  primary  disease.  Patients  who  exhibit  little  dropsy 
and  few  or  no  other  symptoms  may  possess  kidneys  which  are  seriously  diseased 
as  will  be  shown  by  urinary  examination.  The  urine  of  the  acute  congestion 
of  the  kidneys  may  be  distinguished  from  that  of  acute  nephritis  by  its  less 
amount  of  albumin,  fewer  hyaline  and  granular  casts  and  the  lack  of  blood 


ACUTE    NEPHRITIS.  687 

and  epithelial  casts.  Sudden  uraemic  attacks  may  be  the  first  evidence  of 
the  disease,  especially  in  the  type  that  is  due  to  the  toxaemia  of  pregnancy, 
although  careful  watching  of  the  pulse  for  an  increase  of  tension  and  of  the 
urine  for  the  appearance  of  albumin,  will  usually  give  warning  of  the  impend- 
ing danger. 

The  prognosis  is  variable.  It  is  unfavorable  in  the  patients  whose  symp- 
toms persist  for  a  month  or  more;  if  these  gradually  diminish  after  a  week  or 
two,  the  urine  clears  and  the  oedema  gradually  is  lessened,  recovery  is  probable. 
The  prognosis  in  children  is  usually  favorable.  The  occurrence  of  ura?mic 
symptoms,  of  pulmonary  oedema  and  of  suppression  of  urine  renders  the  out- 
look grave.     In  rare  instances  sudden  death  may  take  place. 

Treatment.  During  the  course  of  the  disease  rest  in  bed  is  an  absolute 
necessity  and  the  patient  should  be  guarded  against  draughts  and  chilling 
of  the  body  by  warm  covering;  a  night  gown  or  pajamas  of  flannel  are  to  be 
preferred  to  garments  of  cotton  or  linen.  The  ventilation  of  the  room  should 
be  free,  an  apartment  with  a  fire  place  being  most  suitable. 

The  diet  should  consist  exclusively  of  milk  during  the  acuity  of  the  disease, 
for  this  substance  is  usually  well  borne,  is  easily  digested  and  assimilated, 
and  is  nutritious.  It  also  has  the  advantage  that  under  its  employment  the 
albumin  grows  less  in  quantity  and  it  gives  less  nitrogen  to  the  blood  than  does 
meat.  The  quantity  should  be  from  2  to  3  quarts  (2  to  3  litres)  during  the 
twenty-four  hours,  given  frequently  in  small  amounts,  for  instance  a  glassful 
every  two  hotirs.  It  may  be  more  agreeable  to  the  patient  when  diluted  with 
lime,  carbonic  or  Vichy  water  or  when  it  is  flavored  by  the  addition  of  a  little 
coffee.  Its  diuretic  action  may  be  favored  by  the  addition  of  3  to  4  ounces 
(90.0-120.0)  of  lactose  to  the  daily  amount.  Agreeable  substitutes  for  milk 
are  kumyss,  matzoon,  diluted  condensed  milk,  vegetable — oatmeal,  barley, 
arrowroot,  etc. — gruels  and  meat  broths.  The  last  can  hardly  take  the  place 
of  milk  but  may  now  and  then  be  allowed  if  the  patient  chafes  under  a  diet 
exclusively  of  milk.  When  there  is  clearance  of  the  albuminuria  the  first  addi- 
tions to  the  regimen  should  be  green  vegetables,  puree  soups,  bread  and  butter, 
cheese  and  eggs;  later  the  white  meats  may  be  allowed  but  the  red  meats  should 
be  delayed  for  a  considerable  period.  In  connection  with  the  discussion  of 
the  diet  it  would  seem  weU  to  add  a  word  concerning  the  management  of  the 
dropsy  by  means  of  the  dechloridation  treatment.  There  is  in  oedematious 
states  a  retention  of  the  chlorides  in  the  organism  and  this  results  in  a  transu- 
dation from  the  blood-vessels  of  serum  and  a  consequent  dropsy;  if  the  diet 
contains  still  more  chlorides  the  condition  is  augmented,  consequently  it  is 
wise  to  eliminate  these  elements  from  the  food  as  far  as  is  possible;  this  is 
accomplished  by  excluding  foods  containing  much  salt,  and  forbidding  the 
use  of  this  substance  in  the  preparation  of  the  food  or  as  a  seasoning.  This 
subject  will  be  still  further  considered  under  the  treatment  of  chronic  nephritis. 


688  DISEASES    OF    THE    URINARY    SYSTEM. 

With  regard  to  beverages  it  should  be  stated  that  the  patient  is  to  be  encour- 
aged to  take  plenty  of  water,  vmless  marked  dropsy  is  present,  either  plain  or 
carbonated;  it  may  be  flavored  with  fruit  juices  if  more  agreeable.  The 
so-called  cream  of  tartar  lemonade  is  often  well  liked.  It  consists  of  a 
drachm  or  two  (4.0  to  8.0)  of  potassium  bitartrate  added  to  a  pint  (500.0) 
of  boiHng  water  and  flavored  with  lemon  juice  and  a  bit  of  lemon  peel.  It 
is  most  palatable  when  taken  cold. 

The  lumbar  pain  at  the  onset  may  be  relieved  by  the  application  of  hot 
compresses  or  poultices,  a  sinapism,  or  even  by  wet  and  dry  cupping  or  the 
actual  cautery.  These  measures  may,  perhaps,  have  some  influence  upon 
the  inflammation  of  the  kidney.  Wet  cups  should  not  be  employed  in  children 
and  the  dry  cups  should  not  be  allowed  to  remain  long  in  one  spot  since  it  has 
been  stated  that  if  they  remain  too  long  stagnation  of  the  blood  within  the 
capillaries  takes  place  and  consequently  circulation  in  the  kidney  is  delayed 
and  the  congestion  is  augmented  rather  than  relieved. 

The  suppression  of  urine  and  the  lack  of  perspiration,  which  may  appear 
as  an  early  symptom,  necessitate  the  employment  of  the  hot  pack.  This 
procedure  is  carried  out  as  foUows:  A  large-sized  blanket  is  wrung  out  in 
water  as  hot  as  can  be  borne,  wrapped  about  the  patient  and  outside  this  a 
rubber  sheet  is  applied.  The  patient  is  allowed  to  remain  thus  enveloped 
for  from  one  to  two  hours,  during  which  time  hot  drinks  are  given  to  increase 
the  diaphoresis.  By  this  means  free  sweating  is  induced  and  much  of  the  toxic 
excrementitious  matter  which  should  have  been  passed  off  through  the  kidneys 
is  eliminated.  Other  methods  of  producing  diaphoresis  are  by  administering 
a  hot  bath  for  fifteen  or  twenty  minutes,  after  which  the  patient  is  wrapped  in 
blankets;  and  by  the  vapor  or  hot  air  bath  which  is  given  by  arranging  the 
bed  clothing  so  that  an  apparatus  for  generating  steam  or  hot  air  may  pass 
its  product  beneath.  Any  of  these  measures  will  cause  the  patient  to  per- 
spire freely.  At  the  end  of  the  procedure  the  patient  should  be  rubbed  dry 
with  warm  towels,  covered  warmly  and  protected  from  draughts.  The  free 
diaphoresis  is  also  very  useful  in  diminishing  the  oedema  and  in  warding  off 
uraemia.  Sweating  is  also  to  be  advised  in  the  treatment  of  this  latter  con- 
dition. Depletion  through  the  bowels  is  also  important  in  the  management 
of  the  dropsy  and  the  uraemia.  Laxatives  should  be  employed  from  the  on- 
set of  the  disease,  at  first  to  relieve  the  congestion  of  the  kidney,  later  to  assist 
in  removing  the  dropsical  transfusion.  The  salines  are  usually  preferable  to 
the  vegetable  purges;  to  children  we  may  give  the  effervescing  magnesium 
citrate;  this  is  also  useful  in  adults  as  likewise  is  the  Hay  method  of  administer- 
ing magnesium  sulphate;  here  2  ounces  (60.0)  of  Epsom  salts  are  dissolved  in 
an  equal  quantity  of  boiling  water,  when  cool  this  is  taken  during  the  evening 
and  by  the  following  morning  there  will  be  a  noticeable  increase  in  the  urine 
and  several  watery  stools  will  have  occurred.     If  acute  uraemia  is  present 


ACUTE    NEPHRITIS.  689 

even  more  active  purgation  is  necessary,  particularly  if  the  patient  is  uncon- 
scious. Here  we  may  employ  elaterium  in  doses  of  J  of  a  grain  (0.016)  in 
solution  or  a  drop  or  two  (0.065-0.13)  of  croton  oil  diluted  with  a  little  olive 
oil  may  be  placed  upon  the  back  of  the  tongue.  Following  this  procedure 
free  catharsis  will  be  established.  In  the  moderately  severe  instances  of  the 
disease  it  will  suffice  to  secure  a  daily  free  movement  of  the  bowels  by  means 
of  moderate  doses  of  any  acceptable  saline. 

The  administration  of  diuretics  should  be  confined  to  patients  in  whom  the 
urine  is  diminished  and  oedema  is  present,  and  attempts  to  increase  the  urine 
by  means  of  drugs  should  be  deferred  until  it  is  certain  that  this  excretion 
cannot  be  sufficiently  augmented  by  means  of  packs,  hot  baths  and  especially 
by  copious  high  rectal  irrigations  of  hot  normal  saline  solution.  The  latter 
are  among  our  chief  reliances  in  mraemic  and  toxaemic  states  resulting  from 
inflammations  of  the  kidneys,  they  are  stimulating,  diuretic  and  greatly  facili- 
tate the  elimination  of  poisonous  substances  from  the  system.  They  may  be 
given  two  or  three  times  daily,  or  oftener,  if  necessary.  The  quantity  of  saline 
should  be  2  to  3  gallons  (8  to  12  litres),  the  temperature  should  be  from  116°  to 
120°  F.  (46.5°  to  49°  C),  the  tube  (a  soft  rubber  rectal  tube  is  essential)  should 
be  introduced  as  far  as  possible  and  the  force  of  the  flow  should  be  gentle,  the 
bag  being  elevated  but  three  or  four  feet  above  the  patient.  This  measure  is 
usually  superior  to  the  administration  of  diuretic  drugs,  the  latter  often  being 
irritant  to  the  already  impaired  kidneys  and  possibly  causative  of  anuria. 
Even  water,  which  is  an  excellent  diuretic,  will  tend  to  increase  the  dropsy,  and 
consequently  when  we  are  desirous  of  diminishing  the  latter,  should  be  taken 
in  small  quantities  only.  If  absolutely  necessary  the  alkaline  diuretic  drugs 
may  be  employed  and  the  same  is  true  of  digitalis  and  strophanthus,  the  last 
two  being  admissible  only  when  the  blood  pressure  is  low  and  there  is  tendency 
to  cardiac  weakness.  Of  digitalis  the  infusion  is  probably  the  most  effective 
preparation,  the  dose  being  2  drachms  to  |  an  ounce  (8.0  to  15.0);  diuresis 
has  been  brought  about  by  merely  laying  compresses  wet  in  the  hot  infusion 
upon  the  abdomen  of  the  patient.  Caffeine  and  theobromine  are  useful  at 
times. 

It  is  probable  that  we  have  no  means  of  directly  causing  a  diminution  in  the 
albuminuria  although  we  may  give  sodium  tannate  in  daily  doses  of  40  to  60 
grains  (2.66  to  4.0)  with  this  purpose  in  view.  Quinine  tannate — 30  to  40 
grains  (2.0  to  2.66)  daily — and  tannalbin — 30  to  45  grains  (2.0  to  3.0)  daily — 
have  also  been  recommended.  Strontium  lactate,  which  will  in  certain 
conditions  bring  about  a  considerable  diminution  in  the  albumin  content  of 
the  urine,  is  contra-indicated  in  acute  inflammations  of  the  kidneys. 

Excessive  arterial  tension  wliich  may  be  a  precursor  of  a  convulsive  seizure, 
especially  in  the  nephritis  of  pregnancy,  should  be  controlled  by  erythrol 
tetranitrate,  gr.  j-q  to  ^  (0.006  to  0.032)  three  to  four  times  daily  or  glyceryl  ni- 
44 


690  DISEASES    OF    THE    URINARY    SYSTEM. 

trate,  gr.  y^o  to  -^  (0.0006  to  0.0012)  at  similar  intervals.  Threatened  uraemic 
seizures  may  also  be  warded  oS.  by  the  administration  of  hydrated  chloral, 
gr.  3  to  5  (0.2  to  0.33)  three  times  a  day;  this  drug  is  especially  useful  in  the  al- 
buminuria of  pregnancy  where  there  are  restlessness,  sleeplessness  and  other 
nervous  symptoms  and  is  also  efficacious  in  the  ursemic  convulsion.  Here  it 
is  best  given  by  rectal  injection,  the  dose  for  an  adult  being  a  drachm  (4.0), 
and  that  for  a  child  10  to  30  grains  (0.66  to  2.0).  The  heart  should  always 
be  carefully  watched  for  signs  of  weakness  whenever  chloral  is  given. 

The  treatment  of  a  urcemic  attack  consists  first  in  the  control  of  the  convul- 
sion, if  this  is  present.  Chloroform  should  usually  be  given  by  inhalation 
to  a  degree  sufficient  to  cause  a  cessation  of  the  movements  while  the  action' 
of  other  measures  has  not  yet  begun.  Cliloral  is  also  useful  is  suggested  above. 
In  order  to  strike  at  the  cause  of  the  seizure  it  is  necessary  to  undertake  meas- 
ures with  a  view  to  bringing  about  an  elimination  of  the  toxic  substances  in  the 
blood,  the  presence  of  which  has  resulted  in  the  paroxysm,  consequently 
all  the  channels  of  elimination  should  be  opened  by  purges,  diuretics  and 
diaphoretics  as  suggested  in  preceding  paragraphs.  Pilocarpine  is  sometimes 
useful  as  an  adjunct  to  other  diaphoretic  measures  but  should  not  be  given 
if  pulmonary  complications  or  advanced  degeneration  of  the  heart  muscle  are 
present.  Pilocarpine  hydrochloride  may  be  administered  hypodermatically 
in  doses  of  J  of  a  grain  (0.02)  and  repeated  in  half  to  one  hour  if  perspira- 
tion is  not  induced,  or  a  fresh  infusion  made  from  a  drachm  (4.0)  of  jaborandi 
leaves  and  4  ounces  (120.0)  of  water  may  be  injected  per  rectum. 

In  case  of  obstinate  convulsions  venesection  may  be  practiced.  If  weakness 
supervenes  hot  normal  saline  solution  should  be  given  by  hypodermatoclysis 
or  by  rectal  injection.  The  latter  is  indicated  in  all  cases  as  an  aid  to  elimi- 
nation of  toxins  and  as  a  stimulant.  Heart  weakness  and  pulmonary  oedema 
should  be  combated  by  means  of  cardiac  stimulants,  particularly  strychnine, 
and  in  the  latter  condition  oxygen  inhalations  may  be  employed. 

The  nausea  and  vomiting  of  acute  nephritis  may  be  controlled  by  restricting 
the  diet  temporarily,  by  the  administration  of  cracked  ice  and  if  necessary 
gastric  lavage  may  be  employed.  The  ordinary  anti-emetics  also  are  some- 
times useful;  among  the  most  effectual  of  these  may  be  mentioned  cerium  oxa- 
late in  5  to  10  grain  (0.33  to  0.66)  doses  dissolved  in  milk  with  double  the 
amount  of  sodium  bicarbonate,  tincture  of  iodine  or  creosote  in  minim 
(0.065)  doses  and  dilute  hydrocyanic  acid. 

Too  much  stress  cannot  be  laid  upon  the  importance  of  preventing  intes- 
tinal fermentation.  The  occurrence  of  this  is  evidenced  by  the  appearance 
of  indicanuria  and  for  its  relief  intestinal  antiseptics  are  necessary.  An 
excellent  remedy  consists  of  5  grains  (0.33)  of  bismuth  tetraiodophenol- 
phthaleinate  combined  in  a  capsule  with  2  grains  (0.13)  of  rcsorcinol.  One  of 
these  capsules  may  be  administered  three  times  a  day. 


CHRONIC    PARENCHYMATOUS   NEPHRITIS.  69 1 

Haematuria  seldom  needs  treatment  by  itself  but  if  the  renal  haemorrhage 
is  marked  we  may  give  calcium  lactate  in  doses  of  20  grains  (1.33)  three  times 
a  day  with  a  view  to  increasing  the  coagulability  of  the  blood,  and  a  powder 
containing  7^  grains  (0,50)  each  of  powdered  cinchona  and  tannic  acid  has  been 
suggested. 

The  complications  should  be  treated  as  when  occurring  independently. 
The  anaemia  following  the  nephritis  necessitates  the  administration  of  iron,  of 
which  one  of  the  best  forms  is  a  solution  of  iron  vitellin;  this  may  be  given  in 
doses  of  ^  an  ounce  (15.0)  three  times  a  day  to  adults  and  half  this  quantity  to 
children.  In  the  latter  excellent  results  are  obtained  from  the  oflScial  syrup 
of  iron  iodide  in  doses  of  from  7  to  10  drops  (0.5  to  0.66)  three  times  a  day.  In 
cardiac  dilatation  we  may  employ  the  means  suggested  in  the  section  devoted 
to  the  treatment  of  this  condition. 

During  convalescence  all  exposure  should  be  avoided  and  a  sojovurn  in  a 
warmer   climate   is   to   be   advised. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms.  Chronic  Diffuse  Nephritis;  Chronic  Desquamative  or  Chronic 
Tubal  Nephritis;  Chronic  Bright's  Disease. 

Definition.  A  chronic  diffuse  inflammation  of  the  kidneys  characterized 
by  epithelial,  glomerular  and  connective  tissue  changes  with  exudation  from 
the  blood-vessels. 

.Etiology.  This  form  of  chronic  nephritis  may  result  from  the  acute  des- 
quamative nephritis  following  the  acute  infectious  diseases,  exposure  to  cold, 
etc.  It  may  occur  as  a  sequence  of  chronic  malarial  poisoning,  the  abuse  of 
intoxicating  liquors,  syphilis,  chronic  suppuration  and  tuberculosis,  where  it 
is  usually  associated  with  amyloid  changes  in  the  kidney.  The  disease  is 
observed  in  children  who  have  suffered  from  scarlatina  but  seems  more 
common  in  young  adult  males  than  in  older  persons  or  females. 

Pathology.  Early  in  the  disease  the  kidney  is  of  the  large  white  variety; 
the  organ  is  considerably  enlarged,  its  consistence  is  doughy  or  elastic,  the 
capsule  is  thin  and  may  be  easily  detached;  the  denuded  surface  is  whitish 
with  yellowish  spots  and  there  may  be  injection  of  the  capillaries  bounding  the 
lobules  and  of  the  stellate  veins.  Section  of  the  kidney  reveals  a  thickening  of 
the  cortex,  which  is  anaemic  and  white  in  comparison  with  that  of  the  con- 
gested kidney.  The  microscope  shows  the  epithelium  to  be  swollen  and  the 
seat  of  a  granular,  fatty  or  hyaline  degeneration;  the  glomeruli  are  enlarged 
and  their  capillaries  and  epithelium  are  degenerated.  There  is  moderate 
increase  in  the  connective  tissue  throughout  the  kidney;  the  tubules  often 
contain  granular  and  hyaline  casts. 

Later  during  the  course  of  the  affection  the  kidney  becomes  secondarily 


692  DISEASES    OF    THE    URINARY    SYSTEM. 

contracted,  small  and  mottled,  and  is  now  the  seat  more  especially  of  a  chronic 
diffuse  inflammation.  The  capsule  is  thickened  and  adherent,  the  surface 
of  the  organ  is  granular.  Section  reveals  a  firm  consistency,  a  narrowed  and 
pale  cortex  and  opaque  areas  of  yellowish-white  color  consisting  of  fatty  epithe- 
lium collected  in  the  convoluted  tubules.  The  changes  in  the  interstitial 
connective  tissue  are  more  marked  than  in  the  large  white  kidney,  the  walls 
of  the  blood-vessels  are  thickened,  the  epithelium  of  the  glomeruli  and  of  the 
convoluted  tubules  is  degenerated  and  the  former  may  be  obliterated  by  inter- 
stitial over-growth. 

The  so-caUed  chronic  hcsmorrhagic  nephritis  is  a  form  of  the  chronic  paren- 
chymatous type  of  the  disease.  Pathologically  the  chief  distinction  of  this 
variety  of  the  inflammation  is  the  occurrence  of  brown  foci,  due  to  hjemor- 
rhage,  in  the  cortex  both  within  and  about  the  tubes.  Associated  with  this 
manifestation  are  the  conditions  described  above. 

Hyaline  degeneration  of  the  vessels  of  the  kidney  is  a  frequent  accompani- 
ment of  the  lesions  of  chronic  diffuse  nephritis.  Arterial  degeneration  through- 
out the  body  and  cardiac  hypertrophy  may  be  mentioned  as  frequently  co-ex- 
isting. 

Symptoms.  The  symptoms  of  an  acute  nephritis  may,  without  distinct 
separation,  merge  into  those  of  a  chronic  parenchymatous  nephritis,  or  the 
disease  may  begin  gradually  with  indefinite  symptoms  of  increasing  weakness 
or  indigestion,  until  the  suggestive  paleness  of  the  skin  and  the  oedema  of  the 
lower  eyelids  and  of  the  feet  draw  the  attention  to  the  possibility  of  renal 
disease.  The  dropsy  steadily  ascends  the  legs  but  in  the  early  stages  may  be 
only  slight  on  rising  in  the  morning.  As  the  day  wears  on  it  increases.  Ulti- 
mately the  oedema  becomes  general,  affecting  the  subcutaneous  tissues  of  the 
entire  body;  it  is  often  especially  marked  in  the  penis  and  scrotum.  The 
serous  sacs  may  fill  with  fluid  and  pulmonary  and  glottic  oedema  may  appear 
with  little  or  no  warning  and  result  in  death. 

Anaemia  is  constant  and  characteristic,  and  results  in  a  pasty  color  of  the 
skin  which,  with  the  accompanying  puffiness  of  the  facies,  often  gives  a  very 
certain  clue  to  the  diagnosis.  Accompanying  this  symptom  is  a  gradually 
increasing  weakness.  Dyspnoea  is  frequent,  resulting  from  the  interference 
with  respiration  due  to  the  presence  of  pleural  transudate,  to  the  general 
weakness  of  the  patient  or  to  the  cardiac  condition.  The  heart  is  at  first 
hypertrophied,  more  especially  its  left  ventricle;  later  dilatation  may  ensue. 
There  is  increase  in  the  tension  of  the  pulse  with  an  accentuation  of  the 
second  aortic  sound. 

Nausea  and  vomiting  with  intestinal  fermentation  due  to  improper  action  of 
the  liver,  are  common;  colonic  ulcerations  may  occur  and  terminate  in  death. 

Uraemic  convulsions  are  not  observed  but  headache,  dizziness,  insomnia 
and  stupor,  followed  by  delirium  or  coma  and  ending  fatally,  are  not  rare. 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  693 

Retinal  changes  are  less  frequent  than  in  chronic  arterial  nephritis  but  the 
so-called  albuminuric  neuro-retinitis  may  be  present  and  cause  dimness  of 
sight  and  diminution  of  the  visual  field. 

The  urine  is  diminished  in  quantity  in  the  earlier  stages  but  later  it  may  be 
nearly  or  quite  normal  in  amount;  when  scanty  it  is  of  high  specific  gravity 
and  dark  in  color  and  often  turbid.  On  standing  an  amorphous  precipitate 
consisting  of  urates,  blood  cells,  casts,  granular  detritus,  etc.,  appears.  The 
albumin  content  is  often  large,  3  to  4  percent,  by  weight,  and  usually  is  in 
greater  quantity  in  the  urine  passed  during  the  day.  The  total  content  of 
urea  is  diminished.  The  microscope  reveals  the  presence,  first  of  epithelial 
casts,  later  granular  casts  appear  and  still  later  those  of  the  fatty  and  hyaline 
types;  red  blood  cells,  leucocytes,  epithelial  and  granular  debris  are  often  to  be 
found.  Indicanuria  is  often  present  and  indicates  an  auto-intoxication  due  to 
insufficient  elimination  on  the  part  of  the  liver  and  intestine.  The  resulting 
toxins  act  upon  the  already  impaired  kidney  to  its  further  detriment. 

The  diagnosis  in  certain  instances  is  very  simple,  the  pallor  and  puffi- 
ness  of  the  face  being  characteristic,  the  saying  "large  white  patient,  large 
white  kidney  "  proving  oftentimes  true.  When  the  examination  of  the  urine 
shows  a  diminished  amount,  increased  weight,  diminished  urea,  considerable 
quantity  of  albumin  and  casts  as  described  above,  the  problem  is  not  a  diffi- 
cult one,  particularly  in  connection  with  a  typical  history.  It  is  often  diffi- 
cult to  distinguish  between  the  large  white  and  the  small  white  or  mottled 
kidney;  the  differentiation  is  fortunately  of  no  great  practical  importance. 
Points  in  favor  of  the  smaU  kidney  are  an  increased  amount  of  urine,  lower 
specific  gravity,  less  albumin  and  a  history  of  long  diu-ation.  The  kidney 
of  hyaline  degeneration  is  usually  accompanied  by  enlargement  of  the  other 
viscera,  there  is  less  oedema,  albumin  and  casts  are  more  scanty  and  cardiac 
hypertrophy,  retinal  involvement  and  uraemic  symptoms  are  not  present. 

The  prognosis  is  always  unfavorable  but  life  in  comparative  comfort  may 
be  continued  for  a  number  of  years,  the  symptoms  disappearing  and  the 
albuminuria  clearing  to  a  considerable  extent;  unfortunately,  however,  sooner 
or  later  the  oedema  and  other  manifestations  reappear  and  the  patient  finally 
dies  from  uraemia,  exhaustion,  heart  failiire,  pulmonary  oedema  or  secondary 
inflammations  of  the  serous  sacs. 

It  is  rare  to  see  recovery  take  place  after  the  disease  has  lasted  for  a  year 
but  this  circumstance  may  occur,  particularly  in  children. 

Patients  whose  urine  is  markedly  diminished,  who  excrete  but  little  urea  and 
a  persistently  large  quantity  of  albumin,  and  in  whom  cardiac,  arterial  and 
retinal  degenerations  are  present,  have  little  chance  of  recovery. 

Treatment.  With  regard  to  prophylaxis,  too  great  stress  cannot  be  laid 
upon  the  importance  of  daily  qualitative  and  quantitative  examination  of 
the  urine  in  all  the  acute  infections;  this  should  be  continued  until  recovery. 


694  DISEASES    OF    THE    URINARY    SYSTEM. 

If  the  kidney  is  damaged  the  urine  should  be  watched  with  particular  care 
for  the  occurrence  of  indican  which  by  its  presence  shows  that  there  is  an 
auto-toxaemia  due  to  the  non-elimination  of  intestinal  poisons  through  the 
liver.  These  toxic  substances  are  most  deleterious  to  the  kidneys  and  should 
be  gotten  rid  of  as  quickly  as  possible  by  hastening  their  elimination  by  purging 
and  the  process  of  high  intestinal  irrigation  with  normal  (0.9  percent.)  salt 
solution.  Their  further  formation  should  be  prevented  by  regulation  of  the 
diet — cutting  off  the  carbohydrates — and  the  administration  of  intestinal 
antifermentives  such  as  bismuth  naphtholate  (orphol)  or  tetraiodophenol- 
phthaleinate,  5  grains  (0.33)  of  either  of  which  may  be  given  three  or  four 
times  daily. 

The  treatment  of  chronic  parenchymatous  nephritis  is  first  of  all  dietetic. 
While  a  strict  milk  diet  formerly  was  considered  an  essential,  the  work  of 
von  Noorden  and  others  seems  to  prove  that  a  mixed  regimen  may  be 
allowed,  at  least  in  certain  instances,  without  detriment  and  certainly  to  the 
great  comfort  of  the  patient.  The  diet  should  be  regulated  upon  the  data 
obtained  upon  the  examination  of  the  urine  and  upon  the  amount  of  oedema. 
An  abnormal  quantity  of  urates  in  the  urine  indicates  too  much  proteid; 
indicanuria  shows  that  intestinal  fermentation  is  present  as  a  result  of  too 
free  ingestion  of  starch  and  sugar;  consequently  the  feeding  should  be  arranged 
with  a  view  toward  maintaining  a  proper  balance  between  the  intake  and  the 
output.  When  the  dropsy  and  albuminuria  are  marked  the  diet  should  be 
limited  to  milk  or  buttermilk,  preferably  diluted  with  carbonic,  lime  or 
Vichy  water  (fermented  milks  such  as  kumyss  or  matzoon  are  usually 
better  borne  than  plain  milk  if  the  period  of  administration  is  long),  dry  toast, 
zwieback  or  biscuits;  if  the  oedema  and  albuminuria  are  but  slight  we  may 
be  more  liberal,  allowing  in  addition  to  the  above,  vegetables,  especially  those 
whose  iron  content  is  small,  cereals,  fruits  and  small  amounts  of  meat,  white 
or  red.  Irritating  condiments  must  be  forbidden;  asparagus,  which  for- 
merly was  considered  as  something  to  be  totally  excluded  from  the  diet  of  the 
nephritic,  has  been  proven  to  be  harmless. 

While  dealing  with  the  question  of  diet  the  important  subject  of  the  treat- 
ment of  dropsical  conditions  by  means  of  dechloridation,  or  the  restriction  of 
salt  from  the  food,  should  be  considered.  In  chronic  parenchymatous  neph- 
ritis the  kidneys  excrete  but  a  small  amount  of  chlorides  and  consequently 
these  substances,  being  taken  into  the  organism  in  greater  quantity  than 
they  are  eliminated,  accumulate  within  the  system.  This  retention  results 
in  dropsical  conditions. 

Chloride  retention  in  nephritic  patients  varies  greatly  in  different  instances, 
but  whether  transient  or  permanent,  slight  or  intense,  it  is  governed  by  the 
impermeability  of  the  kidneys  to  sodium  chloride;  therefore,  the  indications 
as  to  duration  and  strictness  of  the  limitation  of  the  chloride  intake  depend 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  695 

upon  the  condition  of  the  patient  in  hand.  Fortunately  we  have  a  very  simple 
means  of  estimatmg  these  indications,  namely,  by  daily  weighing  of  the 
patient.  By  carrying  out  this  procedure  the  physician  possesses  a  method  of 
following  step  by  step  the  effect  of  the  prescribed  diet.  Loss  of  weight  signi- 
fies diminution  of  the  oedema.  A  sample  diet  containing  but  a  small  amount 
of  chloride  is  appended.  Bread  made  without  salt,  10  ounces  (300.0),  beef,  10 
ounces  (300.0),  potatoes,  10  ounces  (300.0),  cooked  in  about  2  ounces  (60.0)  of 
unsalted  butter.  For  drink,  a  quart  (i  litre)  of  water  with  6  ounces  (180.0) 
of  coffee  and,  if  desirable,  10  ounces  (300.0)  of  wine,  may  be  allowed.  Daily 
weighing  of  the  patient  enables  us  to  follow  from  day  to  day  the  progress  of 
the  chloride  eUmination  and  to  regulate  the  rigorousness  of  the  treatment 
in  accordance  with  the  chloride  retention,  and  in  the  intervals  of  marked 
chloridaemia  we  have  a  means  of  testing  the  impermeability  of  the  kidneys 
to  sodium  chloride.  Thus  we  can  avoid  unnecessarily  depriving  the  patient 
of  salt  and  we  are  able  to  detect  at  once  any  threatened  retention  of  chlorides 
which  we  may  avert,  or  at  least  moderate,  by  insistence  upon  a  regimen  lack- 
ing in  salt. 

The  administration  of  theobromine  in  doses  of  10  grains  (0.66)  three  times 
daily  in  connection  with  the  decliloridation  treatment  is  an  important  adju- 
vant. This  drug  increases  the  effect  of  the  restricted  diet  but  cannot  replace 
it;  by  prescribing  throbromine  together  with  a  diet  low  in  chlorides  it  is  possible 
to  free  a  nephritic  patient  from  the  distressing  di-opsy  so  often  observed  in 
kidney  lesions. 

The  albuminuria  of  chronic  parenchymatous  nephritis  may  be  greatly 
reduced  by  putting  the  patient  to  bed  and  at  the  beginning  of  treatment  this 
measure  is  always  advisable;  later  when  the  more  distressing  symptoms  have 
become  ameliorated  the  sufferer  may  be  allowed  up  and  may  even  take  moder- 
ate exercise.  Fresh  air  and  out-door  life  are  particularly  necessary  in  this 
disease.  The  clothing  should  be  of  linen  mesh  or  wool  next  the  skin  for  it  is 
most  essential  that  chilling  of  the  surface  shall  be  prevented,  since  cold  inter- 
feres with  the  eliminatory  action  of  the  skin  and  may  produce  an  acute  exac- 
erbation of  the  chronic  renal  inflammation;  even  suppression  of  urine  has 
been  known  to  follow  exposure  to  cold  and  wet. 

The  administration  of  strontium  lactate  is  often  an  efficient  measure  in  re- 
ducing the  quantity  of  albumin  excreted  in  the  urine  but  this  drug  should 
not  be  employed  when  any  acute  process,  as  evidenced  by  the  presence  of 
epithelial  or  blood  casts  or  of  red  blood  cells,  is  present.  The  proper  dosage 
of  this  agent  is  from  30  to  40  grains  (2.0  to  2.66)  daily,  well  diluted. 

The  anaemia  which  may  be  less  extreme  than  the  paleness  of  the  skin  would 
lead  one  to  suspect,  necessitates  the  exhibition  of  iron.  The  dropsy  may  be 
diminished,  in  addition  to  its  treatment  by  regulation  of  the  diet  as  dis- 
cussed in  a  previous  paragraph,  by  the  means  suggested  under  the  treat- 


696  DISEASES    OF    THE    URINARY    SYSTEM. 

ment  of  acute  nephritis.  Aspiration  of  tlie  pleural  and  peritonaeal  cavities 
is  often  necessary.  The  extreme  tension  of  the  skin  of  the  lower  limbs  result- 
ing from  marked  oedema  may  be  relieved  by  making  numerous  punctures 
with  a  needle  or  by  incisions  of  considerable  size  in  the  region  of  the  ankles. 
The  so-called  Southey's  tubes  may  also  be  used.  The  tube  consists  of  a 
fine  trocar  and  canula,  the  former  being  withdrawn  after  the  puncture  is 
made  and  the  latter  left  in  situ.  To  its  outer  extremity  a  fine  rubber  tube 
may  be  attached  and  led  to  a  vessel  which  will  collect  the  seriim.  All  the 
surgical  procedures  mentioned  above  should  be  carried  out  with  the  utmost 
precautions  as  to  asepsis  for  septic  infection  added  to  the  primary  condition 
is  a  serious  matter. 

The  oedema  of  the  glottis,  which  sometimes  appears,  should  be  promptly 
scarified  or  if  this  fails  intubation  or  tracheotomy  should  be  practiced. 

The  uraemic,  cardiac  and  other  symptoms  and  complications  should  be 
treated  as  when  occurring  in  acute  nephritis. 

Surgical  treatment  by  means  of  decapsulation  of  the  kidney,  if  applicable 
in  any  form  of  chronic  nephritis,  may  possibly  benefit  the  patient's  condition 
in  this  type  of  the  disease  by  establishing  a  collateral  circulation  which  will 
relieve  the  kidney  of  its  accumulated   toxic    substances. 

The  operation  consists  in  exposing  the  organ  and  peeling  off  the  capsule 
in  its  entirety  to  within  a  short  distance  of  its  junction  with  the  renal  pelvis. 
It  is  a  useless  procedure  except  in  rare  instances  of  chronic  parenchymatous 
nephritis. 

CHRONIC  ARTERIAL  NEPHRITIS. 

Synonyms.  Chronic  Interstitial  Nephritis;  Contracted  Kidney;  Cirrhosis 
of  the  Kidney;  Renal  Sclerosis;  Gouty  Kidney. 

Definition.  A  chronic  sclerosis  of  the  blood-vessels  of  the  kidney  occur- 
ring as  a  part  of  a  general  arteriosclerosis  and  connective  tissue  inflamma- 
tion of  the  viscera.  It  is  not  properly  an  inflammation  of  the  kidneys 
but  a  part  of  a  generalized  sclerotic  process. 

^Etiology.  Being  merely  a  localized  manifestation  of  a  sclerosis  affect- 
ing all  the  arteries  of  the  body,  the  causation  of  chronic  arterial  nephritis, 
perhaps  more  properly  denominated  chronic  arterial  degeneration  of  the 
kidneys,  is  identical  with  that  of  arteriosclerosis  in  general.  It  is  rarely  seen 
in  individuals  under  forty  years  of  age  and  is  more  common,  in  males,  be- 
cause of  their  more  frequent  exposure  to  the  direct  setiological  factors  of  the 
degeneration. 

Gout,  syphilis  and  chronic  plumbism  are  important  causes  and  a  history 
of  excessive  use  of  alcohol  and  over-eating,  especially  when  associated  with 
life  at  high  mental  and  physical  tension,  is  very  frequently  met  in  patients 
with  this  affection.     It  is  probable  that  the  disordered  metabolism  from  which 


CHRONIC    ARTERIAL    NEPHRITIS.  697 

such  individuals  suffer  is  responsible  for  the  occurrence  in  the  circulation  of 
certain  toxic  substances  which  by  their  action  cause  an  over-growth  of  the 
arterial  connective  tissue. 

Certain  families  possess  a  tendency  to  early  arterial  degeneration  and  this 
hereditary  influence  may  be  set  down  as  one  of  the  factors  which  produce 
this  form  of  kidney  lesion. 

The  chronic  passive  congestion  of  the  kidneys  which  occurs  in  cardiac 
lesions  predisposes  to  arterial  degeneration  in  these  organs,  as  also  does  renal 
lithiasis,  and  arterial  nephritis  likewise  occurs  as  a  part  of  the  ordinary  senile 
connective  tissue  changes 

Pathology.  The  morbid  changes  occurring  in  this  affection  are  not  confined 
to  the  kidneys,  and  the  involvement  of  these  organs  usually  does  not  take  place 
until  a  considerable  period  after  the  pathological  process  has  begun  in  the 
general  arterial  system.  The  essential  lesion  is  a  thickening  and  connective 
tissue  degeneration  of  the  intima  of  the  arteries  throughout  the  body,  associated 
with  increase  in  the  connective  tissue  of  the  viscera.  The  kidney  of  chronic 
arterial  degeneration  is  the  small,  red  granular  kidney  with  thickened  and 
adherent  capsule.  The  organ  may  be  shrunken  to  only  half  its  normal  size, 
its  surface,  especially  after  removal  of  the  capsule,  is  uneven,  granular,  dense 
and  tough,  and  its  color  is  often  red  in  contradistinction  to  the  yellowish- white 
tinge  of  the  kidney  of  the  stage  of  contraction  of  chronic  parenchymatous 
nephritis.  Cysts  containing  watery  or  viscid  fluid  are  often  observed  at  the 
surface  of  the  organ;  these  vary  in  size  from  that  of  a  pin-head  to  that  of  a 
good-sized  marble. 

The  kidney  substance  is  dense  and  resistant  to  the  knife.  Section  reveals 
a  great  decrease  in  the  width  of  the  cortex  and  a  less  marked  shrinkage  of  the 
medullary  substance;  the  walls  of  the  arteries  are  much  thickened  and  the 
Malpighian  bodies  shrunken;  cysts  may  be  present.  The  pelvis  may  be 
normal  in  size,  enlarged  or  decreased.  The  surrounding  fatty  tissue  is  often 
much  increased  in  amount. 

Microscopic  examination  shows  an  increase  in  the  connective  tissue  of  the 
walls  of  the  blood-vessels  and  an  over-development  of  the  interstitial  connective 
tissue  of  the  organ  itself;  this  tissue  is  increased  at  the  expense  of  the  tubules 
and  blood-vessels  which  it  tends  to  obliterate.  Certain  parts  of  the  organ 
may  show  marked  changes  such  as  those  described  above,  while  in  others 
there  is  but  little  interstitial  over-growth.  Certain  of  the  tubules  appear  to  be 
normal  while  others  may  be  dilated,  shrunken  and  obliterated  or  even  entirely 
replaced  by  new  connective  tissue.  The  epithelial  lining  of  those  which 
remain  may  be  in  normal  condition  or  granular;  the  tubes  may  contain  hyaline 
casts.  The  Malpighian  tufts  are  enclosed  by  connective  tissue  and  often  are 
shrunken  and  atrophic.  The  walls  of  the  arteries  are  in  a  condition  of  marked 
sclerosis,  the  intima  is  thickened  and  the  media  is  also  affected,  its  muscular 


698  DISEASES    OF    THE    URINARY    SYSTEM. 

tissue  being  encroached  upon  by  the  increase  in  its  connective  tissue  elements. 
There  is  also  over-growth  of  the  interstitial  tissue  of  the  adventitia.  As  a 
consequence  of  these  changes  the  arteries  become  dilated  and  twisted  and 
the  hyperplasia  of  the  connective  tissue  of  the  organ  itself  may  result  in  their 
final  obliteration. 

Associated  with  the  changes  in  the  kidneys  are  those  of  general  arterio- 
sclerosis, sclerotic  changes  in  the  Hver,  spleen,  lung,  heart  etc.,  and  as  a  result 
of  the  heightened  blood  pressure  and  increased  difficulty  in  forcing  the  blood 
through  the  diseased  arteries,  hj'pertrophy  of  the  last  organ,  especially  of  its 
left  ventricle,  is  frequent. 

The  retinal  abnormalities  which  are  often  associated  with  arterial  nephritis 
are  merely  a  part  of  the  general  arterial  degeneration,  as  a  result  of  which 
haemorrhages  due  to  rupture  of  the  degenerated  arterial  walls  may  occur. 

Symptoms.  The  diagnosis  of  this  condition  is  often  unsuspected  until  the 
appearance  of  a  terminal  uraemic  attack,  but  the  careful  and  thorough  clinician 
may  make  frequent  early  diagnoses  upon  the  occurrence  of  an  accentuated 
aortic  second  sound;  in  other  instances  the  condition  of  the  retina  (see  p.  797) 
as  revealed  by  ophthalmoscopic  examination,  leads  to  the  first  suspicion  of  the 
presence  of  arterial  nephritis.  Urinary  examination,  suggested  by  the  auscul- 
tation of  the  heart  and  inspection  of  the  retina,  reveals  the  following  changes: 
In  quantity  this  excretion  is  increased,  the  polyuria  being  due  to  the  damaging 
effect  of  the  inflammation  upon  the  epithelial  cells  of  the  tubules  which  nor- 
mally absorb  water  from  the  urine  which  has  passed  from  the  glomeruli. 
The  acidity  is  low,  as  is  also  the  specific  gravity,  as  a  result  of  the  low  excretion 
of  total  solids;  the  color  is  light.  The  constant  low  specific  gravity  is  an  impor- 
tant feature  and  urines  so  characterized  are  always  to  be  considered  suspicious. 
The  albumin  content  is  small,  often  merely  a  trace,  and  even  this  may  be 
absent  in  specimens  passed  in  the  early  morning.  Casts,  chiefly  hyaline, 
sometimes  granular,  are  usually  present  but  thorough  sedimentation  of  the 
urine  is  often  necessary  for  their  demonstration.  The  urea  excretion  is  dimin- 
ished; the  total  quantity  passed  in  twenty-four  hoiirs  may  be  as  small  as  20 
or  30  grains  (1.33  to  2.0) — the  normal  amount  being  about  500  grains  (33.0) 
— just  before  an  attack  of  uraemia.  The  urea  content,  as  well  as  the  amount 
of  albumin  present,  varies  with  the  patient's  diet  and  the  amount  of  exercise 
taken. 

The  patient  often  complains  of  a  progressive  physical  weakness  and  various 
visual  disorders  may  occxu"  early  in  the  disease.  Retinal  haemorrhages  are 
not  infrequent  and  retinitis  or  papillitis  may  be  observed.  The  resulting 
impairment  of  sight  is  permanent  but  the  amblyopia  and  amaurosis  which 
sometimes  appear  may  be  merely  temporary.  Tinnitus,  impairment  of  hearing 
and  vertigo  are  not  uncommon. 

Dropsy  is  rare  in  this  form  of  nephritis  but  slight  oedema  of  the  ankles  may 


CHRONIC    ARTERIAL    NEPHRITIS.  699 

be  observed,  and  the  pasty  pallor  of  the  skin  so  characteristic  of  chronic  paren- 
chymatous nephritis  is  absent;  the  skin,  may,  however,  be  pale  as  a  result  of  the 
anaemia  accompanying  the  disease.  Eczema  with  distressing  pruritus  is  not 
uncommon.  Nose-bleed  and  subcutaneous  haemorrhages  are  frequent  and 
are  due  to  the  tendency  of  the  degenerated  blood-vessels  toward  rupture. 

Hypertrophy  of  the  left  ventricle  is  quite  constant  and  is  evidenced  by  an 
accentuation  of  the  second  aortic  sound,  a  physical  sign  upon  which  alone  the 
diagnosis  of  chronic  arterial  nephritis  may  be  made  in  many  instances.  The 
pulse  is  of  increased  tension  and  there  is  thickening  of  the  walls  of  the  artery. 
It  is  to  overcome  this  increased  resistance  to  the  flow  of  the  blood  current  that 
the  ventricular  hypertrophy  takes  place.  Dilatation  finally  supervenes  and 
with  it  there  is  often  a  relative  mitral  insufiiciency  evidenced  by  an  apical 
ventriculo-systolic  murmur  transmitted  into  the  axilla;  when  the  dilatation 
over-balances  the  hypertrophy  the  signs  and  symptoms  of  uncompensated 
heart  disease  supervene,  such  as  gallop  rhythm,  dyspnoea,  palpitation  and 
vertigo. 

Disorders  of  respiration  due  to  the  co-existent  interstitial  inflammation  in 
the  lungs — chronic  bronchitis  and  emphysema — such  as  dyspnoea  on  exertion 
and  cough,  are  not  rare.  Sudden  attacks  of  marked  dyspnoea,  especially 
at  night  or  early  in  the  morning,  and  due  to  sudden  attacks  of  arterial  contrac- 
tion, may  occur;  oedema  of  the  glottis  or  of  the  lungs  takes  place  at  times. 
Pleural  effusion  is  seldom  seen.  Cheyne-Stokes  respiration  may  be  observed 
as  a  late  symptom. 

Symptoms  referable  to  the  digestive  system  are  common.  The  tongue  is 
often  coated  and  the  breath  may  possess  a  uriniferous  odor.  Dyspepsia  of 
various  types  is  frequent  and  uncontrollable  and  even  fatal  vomiting  and 
diarrhoea  have  been  observed.  Fermentation  in  the  small  intestine  is  evidenced 
by  the  presence  of  indicanuria.  The  resulting  toxic  substances,  particularly 
lactic,  butyric,  oxybutyric  and  acetic  acids,  increase  the  tendency  to  the 
production  of  sclerotic  changes  in  the  arterial  and  other  systems. 

Cerebral  manifestations,  headache,  neuralgic  pains  and  apoplectic  seizures 
due  to  intracranial  haemorrhages,  are  frequent. 

Uraemia  is  a  late  symptom  and  often  a  terminal  one;  it  is  usually  accom- 
panied by  a  rise  in  temperature  and  may  be  evidenced  by  headaches,  vertigo, 
convulsions,  stupor  or  delirium. 

The  complications  are  essentially  the  same  as  those  of  chronic  parenchym- 
atous nephritis. 

The  diagnosis  may  not  be  made  until  the  patient  has  reached  the  autopsy 
table  but  should  any  symptoms  have  arisen  during  life  suggesting  the  need  of 
urine  examination,  the  characteristic  findings  at  once  suggest  the  presence  of 
the  disease.  The  diagnosis  is  often  made  by  the  ophthalmologist  and  the  pres- 
ence of  continued  hicrh  arterial  tension  or  an  accentuated  second  aortic  sound 


yoo  DISEASES    OF    THE    URINARY    SYSTEM. 

should  always  lead  to  suspicion.  Differentiation  from  the  later  stages  of  a 
chronic  parenchymatous  nephritis  may  be  diflScult;  the  history  will  help  us 
here  and  the  presence  of  fatty  and  granular  casts  is  more  characteristic  of  the 
latter  condition. 

The  prognosis  as  to  recovery  is  distinctly  unfavorable  but  the  existence  of 
the  disease  is  not  at  all  incompatible  with  the  prolongation  of  life  for  years 
and  does  not  interfere  with  the  patient's  pursuits  so  long  as  these  are  properly 
regulated.  After  the  appearance  of  uraemic  symptoms  the  probability  of 
betterment  is  little,  but  under  proper  treatment,  even  patients  who  have  not 
been  seen  until  the  occurrence  of  these  manifestations,  may  be  relieved  to  a 
marked  extent.  Unfavorable  symptoms  are  convulsions,  delirium,  coma, 
persistent  vomiting  and  diarrhoea. 

Treatment.  The  patient  should  lead  a  quiet  life  both  mentally  and  physi- 
cally and  all  conditions  which  are  likely  to  put  any  excessive  strain  upon  the 
circulatory  system  or  the  kidneys  are  to  be  carefully  avoided.  Moderate 
exercise  should  be  advised  and  with  it  a  life  in  a  temperate  climate,  or,  if  the 
latter  is  impossible,  careful  avoidance  of  wetting  the  feet,  of  exposure  to  ex- 
tremes of  temperature  and  to  dampness  must  be  insisted  upon.  Clothing  such 
as  that  suggested  under  the  treatment  of  chronic  parenchymatous  nephritis 
should  be  worn.  Tobacco  and  alcohol  are  not  permissible  but  the  moderate 
use  of  tea  and  coffee  need  not  be  discontinued. 

The  proper  diet  is  a  mixed  one  so  regulated  as  to  maintain  the  patient's 
nourishment  without  physiological  improvidence.  It  should  contain  enough 
but  not  too  much  of  the  carbohydrate  element  and  also  sufficient  proteid  in 
readily  oxydizable  form  (beef  particularly).  The  proper  proportion  of  starch 
and  proteid  may  be  ascertained  by  chemical  examination  of  the  urine,  too 
plentiful  carbohydrates  (especially  too  much  sugar)  being  evidenced  by  indi- 
canuria  accompanied  by  intestinal  fermentation,  and  proteid  in  too  large 
amount  by  a  superabundance  of  urates  and  uric  acid.  In  general  the  regimen 
appropriate  in  chronic  parenchymatous  nephritis  is  suitable  here.  The 
diet  lacking  in  chlorides  should  be  prescribed  when  dropsical  conditions  are 
present.  Moderation  in  eating  as  well  as  in  all  other  things  must  be  insisted 
upon.  A  moderate  amount  of  water  should  be  taken,  one  quart  (one  litre) 
daily  is  usually  sufficient;  excessive  water  drinking  is  to  be  discouraged  since 
it  increases  the  fluid  elements  of  the  blood  and  consequently  raises  blood 
pressure,  and  its  excretion  puts  additional  work  upon  the  impaired  kidney. 
With  regard  to  the  kind  of  water  little  is  to  be  said;  practically  the  only 
essential  is  that  it  shotild  be  pure.  The  much-vaunted  lithia  waters  are  quite 
suitable,  not  because  of  the  infinitesimal  amount  of  lithia  which  they  contain 
but  because  they  are,  as  a  rule,  pure;  the  same  may  be  said  of  nearly  all  other 
mineral  waters.  Even  though  benefit  is  not  to  be  expected  from  drinking 
the  waters,  a  yearly  sojourn  at  such  resorts  as  those  at  Poland,  Maine,  Saratoga, 


CHRONIC    ARTERIAL    NEPHRITIS.  70I 

etc.,  and  similar  ones  in  Europe,  is  advisable  when  the  circumstances  of  the 
patient  permit. 

A  daily  warm  bath  should  be  taken,  but  just  as  chilling  the  body  through 
exposure  to  the  inclemencies  of  the  weather  may  precipitate  a  uraemic  seizure 
and  should  consequently  be  avoided,  the  cold  bath,  and  especially  the  prolonged 
sea  bath,  may  bring  about  this  most  undesirable  occurrence.  Turkish  and 
Russian  baths  are  often  beneficial  but  from  these  the  cold  plunge  should  be 
eliminated. 

A  free  movement  from  the  bowels  should  be  secured  daily  by  means  of  saline 
laxatives  or  waters  such  as  Hunyadi  Janos,  Apenta,  etc.,  and  an  occasional 
course  of  fractional  doses  of  calomel  may  be  prescribed  to  advantage,  par- 
ticularly if  intestinal  auto-intoxication,  due  to  fermentation  and  lack  of 
elimination,  is  present.  The  administration  here  of  intestinal  antiseptics 
is  also  necessary  as  under  like  circumstances  in  chronic  parenchymatous 
nephritis. 

The  anaemia  necessitates  the  use  of  tonics,  such  as  iron,  quinine,  arsenic  and 
strychnine,  but  it  must  not  be  forgotten  that  iron  may  be  harmful  in  the  kidney 
of  chronic  arterial  degeneration;  it  is  said  to  cause  headache,  interfere  with 
elimination  and  predispose  to  the  occurrence  of  uraemia.  On  the  other  hand 
tincture  of  iron  chloride  is  considered  by  some  clinicians  of  marked  value 
in  the  anasmia  of  chronic  nephritis;  it  is  recommended  in  doses  of  30  to  60 
minims  (2.0  to  4.0)  three  times  a  day  and  is  said  to  have  the  additional  effect 
of  lessening  arterial  tension.  In  moderate  anaemia  of  chronic  arterial  neph- 
ritis the  elixir  of  iron,  strychnine  and  quinine  of  the  National  Formulary  is 
an  excellent  preparation. 

One  of  the  most  important  considerations  in  the  treatment  of  this  disease 
is  the  opening  of  the  arteries  by  means  of  the  vaso-dilator  drugs.  By  this 
measure  we  relieve  the  h}qDertrophied  and  over-worked  heart  and  increase  the 
blood  supply,  and  consequently  the  nutrition,  of  every  organ  and  tissue  of  the 
body.  The  nitrites  are  most  useful  here  especially  erythrol  tetranitrate — 
which  though  a  nitrate  has  an  analogous  action  to  this  series  of  drugs;  this  agent 
when  given  in  doses  of  J  a  grain  (0.032)  achieves  its  maximum  effect  in  about 
one  hour;  this  effect  persists  for  about  six  hours,  consequently  by  giving  four 
doses  during  the  twenty-four  hours  we  can  keep  the  patient's  arteries  properly 
open.  Tolerance  to  this  drug  is  not  easily  established  and  its  administration 
can  be  continued  for  long  periods.  It  is  best  prescribed  in  the 'form  of  pills 
with  kaolin  or  lycopodium  as  an  excipient  for  if  it  is  mixed  with  an  oxydizable 
substance  it  will  explode.  Glyceryl  nitrate  is  second  in  its  usefulness  only  to 
erythrol  tetranitrate  but  is  inferior  in  that  its  effect  is  less  persistent,  lasting 
but  from  two  to  three  hours.  It  must,  then,  be  given  at  frequent  intervals  in 
order  that  its  action  shall  be  continuous.  The  dose  varies  with  different  pa- 
tients and  should  be  regulated  according  to  the  effect  produced.     One  should 


702  DISEASES    OF    THE    URINARY    SYSTEM. 

usually  begin  with  y^^  of  a  grain  (0.0006)  which  may  be  repeated  at  frequent 
intervals,  the  patient  being  watched  meanwhile  for  toxic  symptoms  such  as 
dizziness,  flushing  of  the  face,  a  feeling  of  fuhiess  in  the  head  and  headache. 
Sodium  nitrite  is  another  useful  drug  of  this  class  but  is  difficult  to  obtain  in  a 
state  of  purity,  being  almost  always  contaminated  by  nitrates.  Its  maximum 
effect  is  reached  in  two  hours  and  lasts  from  four  to  six  hours;  its  dose  is  from 
3  to  5  grains  (0.2  to  0.33).  In  employing  the  vaso-dilator  drugs  the  object  is 
to  relieve  the  heart  by  reducing  the  arterial  tension  and  to  lessen  the  tendency 
to  arterial  ruptiire.  It  is,  however,  necessary  to  provide  against  too  great 
lowering  of  the  blood  pressure  for,  if  this  happens,  oedema  and  effusions  into 
the  serous  sacs  are  likely  to  take  place. 

The  already  increased  amount  of  urine  of  the  early  stages  renders  the  use 
of  diuretics  unnecessary  but  late  in  the  disease  they  may  be  employed  as  in 
chronic  parenchymatous  nephritis. 

Haemorrhages  are  treated  as  when  occurring  in  other  conditions;  apoplectic 
attacks  necessitate  the  application  of  an  ice  helmet,  venesection  if  the  blood 
pressure  is  high,  the  administration  of  potassium  iodide  in  the  later  stages  and 
the  employment  of  the  other  measures  suggested  under  the  treatment  of 
apoplexy.  Bleeding  from  the  mucous  membranes  should  be  treated  according 
to  the  usual  methods.  Benefit  is  usually  gained  by  giving  calcium  lactate 
in  doses  of  20  grains  (1.33)  three  times  a  day  for  a  short  period.  Other 
complications  should  be  managed  as  when  occurring  independently. 

Uraemia  is  handled  according  to  the  methods  suggested  under  the  treat- 
ment of  acute  and  chronic  parenchymatous  nephritis. 

In  other  regards  than  those  mentioned,  the  treatment  of  chronic  arterial 
degeneration  of  the  kidneys  is  identical  with  that  of  arteriosclerosis  in  general 
(q.  v.). 

The  treatment  of  this  form  of  nephritis  by  means  of  decapsulation  of  the 
kidney  is  entirely  useless  as  may  be  plainly  seen  from  a  consideration  of  the 
nature  of  the  disease.  The  general  arterial  system  being  profoundly  affected 
treatment  directed  only  to  the  kidneys  must  of  necessity  be  of  little  avail. 

THE  AMYLOID  KIDNEY. 

Synonyms.    Lardaceous  Disease;  Waxy  Degeneration. 

Definition.  A  chronic  degenerative  process  occurring  in  the  kidneys,  and 
in  other  organs  and  tissues  at  the  same  time,  and  characterized  by  an  infil- 
tration of  the  organ  with  an  albuminous  substance  which  becomes  mahogany- 
brown  in  color  when  wet  with  tincture  of  iodine. 

JEtiology.  This  affection  occurs  as  a  result  of  chronic  suppurative  processes 
especially  those  involving  bone,  such  as  ostoemyelitis  of  pyogenic,  syphilitic 
or  tuberculous  origin;  in  tuberculosis  of  long  standing;  in  syphilis;  in  gout, 


THE    AMYLOID    KIDNEY.  703 

chronic  plumbism  and  leucaemia.  It  is  very  frequent  in  Pott's  and  hip- 
joint  disease. 

Pathology.  The  amyloid  kidney  is  large,  pale  in  color  and  of  smooth 
surface.  If  the  condition  is  uncomplicated  by  interstitial  changes,  the  capsule 
is  not  adherent;  the  stellate  veins  may  be  plainly  visible.  On  section  the  cortex 
is  seen  to  be  thickened,  pale,  firm,  and  may  present  a  characteristic  lustre; 
the  glomeruli  are  prominent.  The  pyramids  are  not  enlarged  and  are  deep 
red  in  color.  Upon  smearing  the  cut  section  with  tincture  of  iodine  the 
mahogany-brown  coloration  above  alluded  to  appears;  in  later  stages  and 
when  the  amyloid  change  is  associated  with  interstitial  increase  of  connective 
tissue,  the  kidney  is  small,  its  capsule  is  adherent  and  its  cortex  narrowed. 
The  hyaline  degeneration  first  involves  the  Malpighian  tufts  and  the  blood- 
vessels; later  the  tubules  may  become  affected.  Microscopically  the  degen- 
eration is  seen  to  involve  both  the  interna  and  the  muscular  coat  of  the  blood- 
vessels, these  are  so  thickened  as  to,  in  certain  instances,  wholly  obliterate 
the  lumen  of  the  vessel.  The  infiltration  of  the  straight  tubules  begins  in  the 
memhrancB  proprice  and  the  tubules  may  contain  waxy  casts.  The  epithelium 
may  be  in  a  state  of  fatty  degeneration  and  glomerulitis  and  thickening  of 
Bowman's  capsule  are  often  present. 

Symptoms.  These  are  not  particularly  characteristic  and  are  apt  to  be 
masked  by  those  of  the  primary  disease.  The  urine  is  pale  in  color,  increased 
in  quantity  and  low  in  specific  gravity.  Albumin  is  usually  present,  often 
in  large  amount;  globulin  also  may  be  found.  Casts  are  frequent  and  are 
usually  hyaline,  although  fatty  and  granular  casts  are  not  seldom  present  as 
well. 

Dropsy  is  not  an  uncommon  symptom,  especially  in  anaemic  and  emaciated 
patients.  It  is  usually  only  moderate  in  degree  and  affects  only  the  lower 
limbs.  Diarrhoea  is  frequent  and  enlargement  of  the  liver  and  spleen  may  be 
observed,  due  to  the  accompanying  amyloid  degeneration  of  these  organs. 
Cardiac  and  arterial  changes  occur  in  those  instances  where  the  amyloid 
condition  is  associated  with  one  of  the  varieties  of  chronic  nephritis;  under 
such  circumstances  they  are  the  rule  and  with  them  are  the  other  symptoms 
of  chronic  nephritis. 

The  diagnosis  is  made  upon  the  concurrence  of  the  urinary  changes  with 
the  primary  and  causative  disease.  The  presence  of  hepatic  and  splenic 
enlargement  are  important  aids.  We  should  suspect  the  amyloid  kidney  in 
all  instances  of  chronic  suppurative  or  wasting  disease  associated  with  increased 
urine  of  low  specific  gravity  and  which  contains  albumin  and  hyaline  casts.  From 
the  two  forms  of  chronic  nephritis  amyloid  degeneration  may  be  separated  by 
the  absence  of  cardiac  and  arterial  manifestations,  the  lack  of  urasmic  and 
ophthalmic  symptoms,  and  by  the  condition  of  the  urine. 

The  prognosis,  while  it  depends  in  great  measure  upon  the  causative  affec- 


704  DISEASES    OF    THE    URINARY    SYSTEM. 

tion,  is  usually  unfavorable;  it  should  be  unnecessary  to  state  that  the  amyloid 
changes  are  permanent. 

Treatment.  Prevention  consists  in  the  early  and  proper  treatment  of 
syphilis,  suppurative  bone  disease  and  of  the  other  conditions  in  which  amy- 
loid degeneration  of  the  kidney  is  likely  to  make  its  appearance.  In  all  such, 
frequent  urinary  examinations  should  be  made  and  upon  the  appearance  of 
albuminuria  the  question  of  radical  removal  of  the  cause  should  be  considered; 
this,  of  course,  is  possible  in  a  limited  number  of  cases  such  as  in  osteomyelitis 
of  a  limb,  tuberculosis  of  the  knee-joint  and  the  like. 

The  treatment  of  the  amyloid  condition  of  the  kidney  occurring  as  a  com- 
plicating disease  is  that  of  the  condition  to  which  it  is  secondary.  Anti- 
syphilitic  and  antituberculous  treatment  should  be  persistently  continued  so 
long  as  symptoms  indicating  the  necessity  for  their  continuance  exist.  The 
general  condition  of  the  patient  should  be  maintained  in  the  best  state  possible 
by  means  of  the  employment  of  nourishing  food,  particularly  milk  and  cream, 
of  codliver  oil,  iron,  strychnine  and  quinine  and  other  tonics,  and  by  insis- 
tence upon  a  life  in  the  open  air,  with  proper  exercise,  and  if  necessary,  change 
of  climate. 

Amyloid  disease  of  the  kidney  after  the  disappearance  of  the  primary  disease 
should  be  treated  by  the  measures,  dietetic,  hygienic  and  medicinal,  advised 
under  the  section  devoted  to  the  treatment  of  the  chronic  nephritides  (q.v.). 

SUPPURATIVE  NEPHRITIS,  PYELONEPHROSIS  AND  PYELITIS. 

Synonyms.  Siirgical  Kidney;  Suppurative  Interstitial  Nephritis;  Septic  or 
Pyaemic  Nephritis. 

These  conditions  being  almost  invariably  very  closely  associated  and  almost 
wholly  surgical  in  treatment,  may  be  considered  together 

Suppurative  nephritis  is  a  pyogenic  inflammation  of  the  kidney  resulting 
from  infection  with  the  bacteria  of  suppuration  which  have  reached  the  organ 
through  the  blood  current  or  more  usually  by  an  ascending  inflammation  of 
the  urinary  tract.  In  the  latter  instance  there  is  first  an  inflammation  of  the 
pelvis  of  the  kidney — a  pyelitis — which  later  spreads  to  the  organ  itself, 
becoming  a  pyelonephritis. 

etiology.  As  a  predisposing  cause  residual  urine  in  the  bladder  is  most 
important;  this  undergoes  decomposition  and  thus  becomes  a  favorable  medium 
for  the  multiplication  of  bacteria,  infection  from  which  ascends  the  ureter,  in- 
volves the  pelvis  of  the  kidney  and  finally  the  kidney  itself.  Kidney  stone  may 
so  irritate  the  organ  as  to  render  its  resistance  less  to  bacterial  infection  and  as 
a  consequence  a  suppurative  process  may  occur.  Infective  ureteritis,  cystitis 
or  urethritis  from  any  cause  may  spread  backward  to  the  pelvis  of  the  kidney 
and  ultimately  involve  the  organ.     A  very  common  cause  of  cystitis  and  sub- 


SUPPURATIVE    NEPHRITIS,    PYELONEPHROSIS    AND    PYELITIS.        7C5 

sequent  infection  of  the  kidney  is  the  introduction  of  dirty  sounds  or  other 
instruments  into  the  bladder. 

EmboHc  infection  through  circulatory  channels  may  take  place  in  malig- 
nant endocarditis  or  pysemic  conditions  of  any  kind,  and  traumatism,  operative 
or  otherwise,  may  so  interfere  with  the  resistance  of  the  organ  that  it  becomes 
an  easy  prey  to  infection.  Exposure  and  the  infectious  diseases  act  as  causes 
in  the  same  way.  Suppurative  kidney  disease  also  occurs  secondary  to  malig- 
nant and  other  tumors  of  the  organ. 

The  infective  organisms  which  have  been  found  in  the  pus  from  the  kidneys 
or  in  the  urine  and  have  been  considered  as  causes  of  the  process,  are  the 
tubercle  bacillus,  the  bacillus  protcus,  the  colon  bacillus,  the  streptococcus 
and  the  staphylococcus. 

Pathology.  In  pyelitis  due  to  ascending  infection,  the  mucous  membrane 
lining  the  kidney  pelvis,  is  swollen  and  congested;  a  grayish  false  membrane 
may  be  present.  Dilatation  of  the  pelvis  and  of  the  calices,  and  flattening 
of  the  papillae  may  take  place.  The  pelvis  often  contains  purulent  urine. 
As  a  result  of  the  infective  process  in  the  pelvis  of  the  organ,  extension  into 
the  kidney  itself  may  follow  (pyelonephritis) ;  the  distention  finally  may  result 
in  atrophy  of  the  substance  of  the  organ  until  the  entire  kidney  becomes  a 
mere  sac  of  pus  surrounded  by  a  shell  of  renal  tissue  (pyonephrosis) ;  in  certain 
instances  if  there  is  an  obstruction  to  the  flow  of  pus  from  the  organ,  the  for- 
mer may  become  cheesy  and  at  times  may  undergo  calcareous  degenera- 
tion. 

Ascending  tuberculous  inflammation  first  mvolves  the  apices  of  the  pyra- 
mids; at  first  the  process  is  limited  but  ultimately  the  kidney  undergoes 
the  changes  described  above,  caseous  and  calcareous  degeneration  of  the 
purulent  contents  of  the  organ  being  common. 

Metastatic  infection  of  the  kidney  is  evidenced  by  the  occurrence  within 
the  organ  of  single  or  multiple  pus  foci  of  varying  size.  These  are  dissem- 
inated through  the  cortex  and  may  coalesce  to  produce  larger  abscess  cavities 
which  destroy  the  structure  of  the  organ  and  may  ultimately  unite  to  convert 
the  kidney  into  a  sac  of  purulent  matter. 

Symptoms.  These,  aside  from  the  urinary  appearances,  are  often  vague. 
Pain  and  tenderness  in  the  lumbar  region  or  deep  in  the  abdomen  are  often 
present  but  may  not  appear  even  when  the  kidney  is  markedly  diseased. 
Impacted  calculi  cause  pain,  which  is  usually  intermittent  in  type,  at  the 
site  of  the  obstruction.  Chills,  fever  and  sweating  are  often  observed  as  a 
result  of  the  septic  condition.  The  chills  are  often  regularly  intermittent 
and  resemble  malarial  paroxysms.  In  the  tuberculous  infections  the  tem- 
perature frequently,  as  the  disease  progresses,  becomes  of  hectic  character. 
The  pulse  rate  is  increased. 

Prolongation  of  the  inflammation  results  in  progressive  weakness  and 
45 


7o6  DISEASES    OF    THE    URINARY    SYSTEM. 

emaciation.  Metastatic  abscesses  and  general  pyaemia  may  result.  Tuber- 
culous pyelitis  sometimes  runs  a  course  resembling  that  of  enteric  fever. 

Dyspnoea  with  cerebral  symptoms  may  occur  and  even  death  in  coma  has 
been  observed  and  has  been  considered  to  be  the  result  of  absorption  of 
toxic  substances  from  the  urine  (ammoniaemia). 

The  urine  contains  pus  in  variable  amount;  this  substance  may  be 
w^hoUy  absent,  if  but  one  kidney  is  diseased,  due  to  a  temporary  ureteral 
obstruction.  There  may  be  sudden  great  augmentation  in  the  quantity  of 
the  pus  due  to  rupture  of  an  abscess  and  the  discharge  of  its  contents.  The 
pus  may  contain  fragments  of  kidney  tissue  if  the  inflammation  is  progressing 
rapidly.  The  quantity  of  the  urine  at  the  beginning  may  be  diminished  but 
in  chronic  cases  it  is  often  increased.  The  specific  gravity  is  low  rather  than 
high  and  the  reaction  is  not  constant;  it  depends  upon  the  micro-organism 
causing  the  disease  and  upon  the  presence  or  absence  of  cystitis  which  is  usu- 
ally accompanied  by  an  alkaline  urine.  With  the  pus,  red  blood  cells  are  also 
present,  though  usually  in  small  number.  Albumin  is  present  varying  with 
the  amount  of  pus  and  red  blood  cells,  although  its  quantity  may  be  greater 
than  can  be  accounted  for  by  these  elements  if  there  is  co-existent  parenchym- 
atous nephritis.  In  the  presence  of  this  complication  pus  casts  and  those 
of  other  varieties  are  observed.  The  urine  contains  a  certain  amount  of 
mucous  and  usually  numerous  epithelial  cells.  The  presence  of  kite-shaped 
epithelial  cells  in  considerable  number  is  very  suggestive  of  involvement 
of  the  renal  pelvis,  although  a  few  of  these  are  often  observed  when  cystitis 
is  the  only  lesion. 

Physical  examination  often  reveals  tenderness  in  the  lumbar  region  of 
the  affected  side  and  palpation  and  percussion  may  give  evidence  of  a  more 
or  less  distinct  tumor  of  varying  size. 

The  diagnosis  is  simple  when  haematxiria  and  pyuria  result  from  injury 
of  the  region  of  the  kidney  and  should  always  be  suspected  when  with  cystitis 
there  is  persistence  of  pus  in  the  urine  with  tenderness  over  the  kidney.  Cysto- 
scopic  examination  may  aid  in  the  diagnosis  and  ureteral  catheterization  will 
definitely  prove  whether  the  pus  is  coming  from  the  renal  pelvis.  The  specific 
cause  of  the  inflammation  can  be  proven  only  by  bacteriological  examination. 
Staining  of  the  sedimented  urine  from  specimens  obtained  by  ureteral  cathe- 
terization may  reveal  the  presence  of  the  tubercle  or  other  bacilli  and  if  this 
fails,  inoculation  experiments  should  be  undertaken. 

The  prognosis  varies  with  the  cause  of  the  disease.  Pyaemic  cases  are 
usually  rapidly  fatal  while  those  complicating  the  infectious  diseases  usually 
recover.  Tuberculous  pyonephrosis  may  result  in  recovery  but  with  the 
kidney  converted  into  a  caseous  or  calcareous  mass.  The  kidney  which  is 
converted  into  a  pus  sac  may  rupture  into  the  peritonaeum  and  any  intercur- 
rent disease  in  a  patient  afflicted  with  kidney  infection  is  quite  likely  to  ter- 


HYDRONEPHROSIS.  707 

minate  unfavorably.  In  fine  it  may  be  said,  however,  that  in  unilateral  sup- 
purative disease  of  the  kidney,  when  not  associated  with  other  affections  and 
when  diagnosticated  early  in  its  course,  nephrotomy  or  removal  of  the  organ 
offers  excellent  hope  of  recovery. 

Treatment.  The  importance  of  early  surgical  interference  cannot  be 
over-estimated  and  the  same  may  be  said  of  the  employment  of  the  scientific 
methods  of  diagnosis,  by  means  of  ureteral  catheterization,  which  have  recently 
been  perfected.  Unilateral  tuberculosis  calls  for  removal  of  the  organ,  and 
abscess  due  to  other  causes,  when  sufficient  renal  tissue  to  functionate  remains, 
for  nephrotomy  and  drainage.  The  treatment  of  pelvic  inflammations  by 
means  of  antiseptic  lavage  through  the  ureteral  catheter  has  been  advocated 
and  co-existent  cystitis  should  also  be  treated  by  irrigations. 

For  the  pain  we  may  employ  hot  compresses,  the  turpentine  stupe,  dry 
cupping  or  the  mustard  paste,  kept  on  until  the  skin  is  well  reddened,  then 
removed  to  be  reapplied  when  the  blush  has  faded.  If  severe,  this  symptom 
usually  necessitates  the  hypodermatic  administration  of  morphine,  J  to  J 
of  a  grain  (0.016  to  0.022)  or  the  employment  of  suppositories  containing  i 
to  2  grains  (0.065  ^^  0.13)  of  opium.  Attempts  should  be  made  to  dilute 
the  urine  by  drinking  freely  of  the  mildly  alkaline  waters  or  of  plain  water. 
Probably  the  only  drug  which  we  have,  which  possesses  any  influence  over 
the  suppurative  process,  is  hexamethylenamine.  This  is  a  urinary  antiseptic 
of  considerable  potency,  although  unfortunately  it  appears  to  have  but  little 
effect  in  tuberculosis  of  the  urinary  tract.  When  given  in  combination  with 
sodium  benzoate,  gr.  v  to  viiss  (0.33  to  0.5)  of  the  former,  gr.  x  to  xv  (0.66  to 
i.o)  of  the  latter,  it  renders  an  alkaline  and  ammoniacal  urine  acid,  lessens 
the  lumbar  pain  and  may  influence  the  amount  of  pus.  Sandal  oil,  of  which 
15  to  20  minims  (i.o  to  1.33)  may  be  taken  three  times  daily  in  capsules,  may 
also  lessen  the  pelvic  inflammation  and  may  be  given  alone  or  in  conjunction 
with  sodium  benzoate  or  benzoic  acid.  The  vegetable  diuretices,  buchu,  kava 
kava,  pichi,  pareira,  etc.,  may  be  employed  but  are  seldom  effective. 

Tonics  should  be  given  to  combat  the  tendency  toward  progressive  weakness 
and  emaciation;  here  codliver  oil,  iron,  quinine  and  strychnine  will  be  found 
useful.  ^ 

The  diet  should  be  bland  and  nourishing;  milk  either  plain  or  fermented 
may  be  drunk  in  considerable  quantity.  The  clothing  should  be  warm  and 
all  exposure  should  be  avoided. 

HYDRONEPHROSIS. 

Synonym.     Nephrydrosis. 

Definition.  An  accumulation  of  urine  in  the  pelvis  and  calices  of  the 
kidney  caused  by  an  obstruction  of  the  ureter  and  resulting  in  more  or  less 
dilatation. 


ycS  DISEASES    OF    THE    URINARY    SYSTEM. 

Etiology.  The  condition  may  be  either  congenital  or  acquired  and  is 
the  result  of  obstruction  of  the  urethra  or  ureter.  Congenital  instances  may 
be  due  to  stricture  of  the  ureter  or  urethra,  the  insertion  of  the  ureter  into  the 
kidney  at  an  abnormally  acute  angle,  to  twists  of  the  ureter  or  to  congenital 
defects  of  the  abdominal  muscles.  The  tumor  caused  by  the  hydronephrosis 
in  the  foetus  may  be  so  great  as  to  interfere  with  parturition. 

Acquired  hydronephrosis  may  result  from  urethral  stricture  or  prostatic 
enlargement,  in  which  case  the  affection  is  bilateral;  from  ureteral  obstruc- 
tion due  to  impacted  calculi;  from  ureteral  stricture  following  ulcerous  or 
other  inflammation;  from  kinking  of  the  ureter  which  may  occur  in  instances 
of  movable  kidney;  from  external  pressure  upon  the  ureter  by  intra-abdominal 
tumors,  uterine  and  ovarian  in  particular,  or  peritonEeal  bands;  from  obstruc- 
tion of  the  cystic  orifice  of  the  ureter  due  to  tumors  (malignant  or  otherwise) 
and  inflammations  of  the  bladder. 

Pathology.  The  condition  is  usually  unilateral,  the  obstruction  to  the 
outflow  of  urinary  secretion  resulting  in  a  gradually  increasing  dilatation  of 
the  pelvis  and  calices  which  presses  upon  the  renal  tissue  and  finally  produces 
atrophy  and  distention  of  the  kidney.  Infection  with  consequent  pyelitis 
and  pyelonephrosis  may  take  place.  In  marked  instances  there  is  inflam- 
matory thickening  of  the  pelvis  of  the  kidney  while  the  organ  itself  is  wasted 
to  a  thin  shell,  in  the  wall  of  which  little  or  no  renal  tissue  remains. 
This  sac  contains  a  thin  yellowish  fluid,  usually  clear,  but  at  times  turbid 
due  to  the  presence  of  small  amounts  of  pus.  The  specific  gravity  is 
low  and  the  reaction  is  often  alkaline.  Small  amounts  of  the  urinary 
salts,  urea  and  uric  acid  are  present  and  perhaps  a  trace  of  albumin  may  be 
found. 

The  ureter  may  be  the  seat  of  marked  dilatation,  depending  upon  the  site  of 
the  obstruction,  and  there  is  often  hypertrophy  of  the  unaflected  kidney  and 
of  the  left  ventricle  of  the  heart. 

Symptoms.  Bilateral  congenital  hydronephrosis  is  incompatible  with  life, 
but  the  unilateral  type  may  cause  no  symptoms  whatever  until  the  result- 
ing tumor  becomes  apparent  upon  inspection  and  palpation.  Acquired 
instances  of  the  disease  also  may  exist  for  considerable  periods  without  being 
evidenced  by  symptoms  or,  if  present,  these  may  be  obscured  by  those  of  the 
causative  disease,  uterine  or  ovarian  turnor,  etc. 

Pain  in  the  lumbar  region  shooting  down  to  the  groin  or  thigh,  a  feeling 
of  weight,  and  a  progressive  loss  of  flesh  are  not  infrequent  symptoms.  With 
these  lack  of  appetite  and  various  digestive  disturbances,  such  as  nausea, 
eructations  and  constipation,  which  may  be  of  obstinate  type  if  the  large 
intestine  is  pressed  upon  by  the  accumulation  of  fluid,  may  be  associated. 
Irritation  of  the  colon  by  pressure,  without  interference  with  the  passage  of 
freces,  may  cause  diarrhoea.     The  patient  may  detect  a  fulness  in  the  region 


HYDRONEPHROSIS.  709 

of  the  kidney  and  in  marked  instances  the  abdomen  may  be  so  distended 
as  to  suggest  ascites. 

Physical  examination  reveals  a  tumor  which  upon  inspection  is  evidenced 
by  a  fulness  of  the  hypochondrium  and  in  the  lumbar  region;  this  tumor  is 
likely  to  enlarge  gradually,  the  increase  in  size  being  detected  by  measur- 
ment  of  the  abdomen  at  intervals.  Upon  palpation  a  rounded,  firm  and 
elastic  tumor  is  felt.  Fluctuation  may  be  elicited  and  tenderness  may  be 
present.  Percussion  over  the  tumor  elicits  a  dull  or  flat  note  unless  the  colon 
passes  between  it  and  the  abdominal  wall;  over  the  colon  the  note  is  tympanitic. 

Intermittent  hydronephrosis  is  an  interesting  condition  in  which  the  tumor 
disappears  or  varies  in  size  from  time  to  time;  this  occurrence  is  due  to  sudden 
removal  of  the  cause  of  the  ureteral  obstruction.  This  is  likely  to  take  place 
in  hydronephrosis  due  to  kinking  of  the  ureter  which  is  common  in  movable 
kidney,  and  also  may  be  observed  when  there  is  a  valvular  stricture  of  the 
ureter  or  an  abnormal  insertion  of  this  structure  into  the  kidney.  With  the 
diminution  in  size  of  the  tumor  comes  a  sudden  increase  in  the  flow  of  urine. 
Previous  to  this  occurrence  colicky  pains  may  be  observed.. 

Uraemia  may  take  place  if  a  double  hydronephrosis  is  present. 

The  diagnosis  is  difficult  if  the  retained  fluid  is  small  in  quantity  but  when 
the  condition  is  evidenced  by  a  gradually  increasing  tumor  in  the  flank  which  di- 
minishes or  disappears  with  greater  or  less  suddenness  with  an  associated  augmen- 
tation of  the  urinary  secretion,  (the  flush-tank  sign)  the  affection  can  hardly  be 
mistaken.  Large  hydronephroses  may  be  confounded  with  ovarian  cysts  or  even 
with  ascites,  but  the  demonstration  of  the  colon  anterior  to  the  tumor  will  exclude 
these  latter  conditions  and  aspiration  of  a  small  portion  of  the  collected  fluid  by 
means  of  an  exploring  needle,  will  reveal  the  characteristic  fluid  of  a  nephry- 
drosis.  Pyonephrosis  is  characterized  by  the  presence  of  a  febrile  move- 
ment and  pyuria.  The  diagnosis  in  doubtful  instances  may  be  confirmed 
by  means  of  ureteral  catheterization.  While  the  obstruction  is  present  little 
or  no  urine  will  be  drawn  through  the  catheter  passed  into  the  ureteral  orifice 
of  the  affected  side. 

The  prognosis  is  usually  grave  although  certain  instances  have  been 
reported  in  which  a  disappearance  of  the  tumor  due  to  unblocking  of  the 
obstructed  ureter  has  not  been  followed  by  re-accumulation.  Rupture  of  the 
sac  rarely  takes  place.  Double  hydronephrosis  is  an  especially  unfavorable 
condition  owing  to  the  danger  of  uraemia,  and  infection  of  the  cyst  contents 
with  resulting  pyonephrosis  is  likely  to  prove  fatal  unless  prompt  surgical 
intervention  is  instituted. 

Treatment.  Hydronephroses  of  intermittent  type  seldom  need  radical 
treatment  and  the  management  of  the  patient  should  be  along  dietetic  and 
hygienic  lines  such  as  those  advised  in  pyelitis  and  pyonephrosis.  Very 
careful  massage  of  the  tumor  in  certain  instances  may  bring  about  a  removal 


yiO  DISEASES    OF    THE    URINARY    SYSTEM. 

of  the  obstruction  and  a  partial  or  complete  emptying  of  the  sac.  All  cases 
should  be  studiously  watched  for  the  occurrence  of  infection  of  the  cyst  con- 
tents. If  the  nephrydrosis  is  due  to  the  movability  of  the  kidney  the  treat- 
ment, after  the  emptying  of  the  sac,  is  that  of  this  condition  (see  p.  676). 

The  treatment  is,  with  the  exception  of  the  above  points,  wholly  surgical, 
and  the  measures  which  may  be  employed  should  be  varied  to  suit  the  case" 
in  hand.  Simple  aspiration  often  becomes  necessary  when  the  quantity  of 
fluid  becomes  large  and  re-accumulation  may  necessitate  a  repetition  of  the 
operation.  The  needle  is  usually  introduced  in  the  flank  at  a  point  midway 
between  the  twelfth  rib  and  the  iliac  crest.  More  radical  procedures  which 
may  be  undertaken  upon  the  advice  of  the  surgeon  are  incision  and  drainage 
of  the  sac  with  establishment,  if  necessary,  of  a  permanent  urinary  fistula,  or 
complete  nephrotomy. 

PARANEPHRITIS. 

Synonyms.    Perinephritis;  Perinephritic  Abscess. 

Definition.  A  suppiurative  inflammation  of  the  connective  tissues  about 
the  kidney. 

.Etiology.  Primary  paranephritis  occurs  as  a  result  of  infection  follow- 
ing traumatisms  of  the  region  of  the  kidneys.  Secondarily  the  condition 
develops  as  a  result  of  one  of  the  acute  infectious  diseases,  especially  in  chil- 
dren; of  extension  of  some  suppurative  process  in  the  kidney  itself,  its  pelvis 
or  the  ureter;  of  intestinal  perforation,  particularly  that  due  to  appendicitis; 
of  spinal  suppuration  and  the  caries  of  Pott's  disease;  and  of  extension  of  an 
empyaema. 

Pathology.  There  may  be  several  small  abscess  cavities  in  the  tissues 
posterior  to  the  kidney,  or  this  organ  may  be  found  lying  in  a  single  abscess 
cavity  of  larger  size.  The  process  usually  begins  behind  the  kidney,  conse- 
quently most  of  the  pus  is  found  in  this  situation,  though  more  rarely  it  may  be 
found  between  the  organ  and  the  peritonaeum.  The  pus  is  often  of  foul 
odor  as  a  result  of  its  contiguity  to  the  large  intestine.  If  the  condition  is 
the  result  of  intestinal  perforation  the  odor  is  likely  to  be  faecal.  The  pus 
most  frequently  burrows  downward  and  may  reach  the  surface  through 
the  tissues  of  the  groin  or  it  may  perforate  the  intestine,  the  peritonaeal  cavity, 
the  vagina  or  the  bladder.  More  rarely  it  works  its  way  outward  through  the 
lumbar  tissues  or  upward  through  the  diaphragm  into  the  lung  whence  it  is 
discharged  through  the  bronchi. 

A  seldom  observed  condition  is  a  chronic  perinephritis  which  has  given  no 
symptoms  during  life  and  which  is  characterized  by  a  firm  and  fibrous  capsule 
surrounding  and  adherent  to  the  true  capsule  of  the  kidney;  this  is  the  result 
of  an  inflammatory  degeneration  of  the  perirenal  fatty  tissue. 


NEPHOLITHI ASIS.  7 1 1 

Symptoms.  In  instances  secondary  to  other  disease  the  symptoms  of  the 
primary  affection  are  present;  suppuration  of  the  perirenal  tissues  is  evidenced 
by  pain  and  tenderness  upon  pressure  in  the  neighborhood  of  the  kidney. 
The  lumbar  tissues  may  be  cedematous.  The  pain  is  referred  not  only  to 
the  region  of  the  kidney  but  also  by  many  patients  to  the  hip  or  knee,  this  is  due 
to  the  pressure  of  the  suppurating  mass  upon  the  nerves  of  the  lumbar  plexus, 
terminal  branches  of  which  are  distributed  to  the  vicinity  of  these  joints. 
While  lying,  the  patient  finds  relief  from  the  pain  by  flexing  the  thigh  of  the 
affected  side  upon  the  pelvis  and  if  able  to  stand,  he  rests  most  of  his 
weight  upon  the  leg  of  the  sound  side  and  stoops  forward.  Adduction  of 
the  thigh  is  difficult  and  painful.  After  the  formation  of  pus  there  are  chills, 
an  irregular  fever  and  sweats.  If  rupture  has  taken  place  into  the  pelvis 
of  the  kidney  or  if  the  perirenal  process  has  resulted  from  pyelitis  or  renal 
suppuration,  there  is  pyuria.  Palpation  of  the  abdomen  and  lumbar  region 
reveals  an  indurated  area  between  the  twelfth  rib  and  the  iliac  crest  and  a 
definite  tumor  may  be  felt  in  some  instances. 

The  diagnosis  is  usually  not  difficult.  The  history  of  traumatism  or  of 
primary  disease  is  important.  Hip  and  knee-joint  disease  may  be  excluded 
by  examination  of  these  parts.  The  tumor  is  less  distinct  in  outline  than  that 
of  renal  abscess  and  in  uncomplicated  instances  the  virine  is  unaffected. 
Movements  of  the  thigh,  especially  adduction  and  flexion,  are  painful. 

The  prognosis  is  most  favorable  in  the  traumatic  cases  and  when  early 
diagnosis  is  made.  Rupture  in  the  lumbar  region  is  more  favorable  than 
into  the  groin,  peritonaeum  or  elsewhere. 

Treatment  is  entirely  surgical  and  consists  in  free  incision,  thorough  evacu- 
ation of  the  pus  and  drainage.  Involvement  of  the  kidney  itself  in  the  sup- 
purative process  may  necessitate  nephrectomy. 

NEPHROLITHIASIS. 

Synonyms.     Renal   Calculus;   Kidney   Stone;   Gravel. 

Definition.  Nephrolithiasis  is  the  term  applied  to  that  condition  of  the 
kidney  and  renal  pelvis  which  is  characterized  by  the  formation  or  presence, 
in  either  of  these  structures,  of  concretions  resulting  from  the  precipitation 
of  any  of  the  solid  elements  of  the  urine. 

.Etiology.  It  is  difficult  to  explain  the  cause  of  the  precipitation  which 
results  in  the  formation  of  a  renal  calculus.  The  condition  is  more  common 
in  men  than  in  women  and  is  chiefly  seen  in  childhood  and  beyond  middle 
life.  Heredity  seems  to  have  a  certain  influence  in  many  instances  and  as 
other  predisposing  causes  sedentary  life,  the  purinaemic  state  and  kindred 
conditions  may  be  mentioned. 

Speaking  generally  it  may  be  stated  that  the  formation  of  calculi  is  encour- 


712  DISEASES    OF    THE    URINARY    SYSTEM. 

aged  by  the  presence  in  the  urine  of  an  excess  of  normal  solid  constituents 
or  of  abnormal  solid  ingredients.  Many  stones  which  have  as  their  origin 
collections  of  bacteria,  bits  of  epithelium  or  mucus,  the  eggs  of  parasites, 
coagulated  blood  and  casts,  around  which  crystals  have  been  deposited,  have 
been  observed,  which  shows  that  the  presence  of  foreign  substances  is  a  causa- 
tive factor  in  many  instances.  Uric  acid  calculi,  the  most  frequent  variety, 
are  believed  to  be  likely  to  occur  in  the  presence  of  a  urine  of  increased 
acidity  containing  a  large  amount  of  uric  acid,  but  a  small  quantity  of  salines 
and  possessing  a  light  color. 

Pathology.  Renal  concretions  may  be  classified  according  to  their  size 
and  their  chemical  constitution.  The  former  classification  is  as  follows: 
a.  Renal  sand  which  consists  of  fine  gritty  particles  which  usually  are  single 
uric  acid  crystals  or  a  number  of  these  adherent  to  one  another,  h.  Renal 
gravel  which  is  made  up  of  coarser  grains  which  may  even  be  larger  than  a 
good-sized  pea.  c.  Renal  stone  which  may  attain  the  size  of  a  hen's  egg. 
These  often  form  casts  of  the  pelvis  of  the  kidney  or  its  calices  and  may  be 
branched  (dendritic  or  coral  calculi).  Chemically  kidney  stones  are  composed 
of:  a.  Uric  acid  and  its  sodium,  ammonium  or  potassium  salts.  These  are 
of  any  size  from  the  largest  to  the  smallest,  and  are  hard,  brownish  or  black 
in  color  and  of  irregularly  smooth  surface,  h.  Calcium  oxalate  (mulberry  calculi). 
These  stones  are  hard,  of  uneven  and  rough  surface,  may  be  of  any  size  and 
are  often  formed  about  a  nucleus  of  uric  acid.  c.  PJiosphatic  calculi  are  less 
common  than  either  of  the  preceding  varieties.  They  often  reach  a  very  large 
size,  are  grayish  or  white  in  color  and  may  be  so  soft  as  to  permit  of  crushing 
between  the  fingers.  They  are  more  frequently  observed  in  the  bladder 
and  are  composed  of  calcium  and  ammonium-magnesium  phosphate  often 
deposited  about  a  nucleus  of  uric  acid  or  calcium  oxalate,  d.  Rarer  varieties 
of  renal  calculus  are  composed  of  cystine,  xanthine,  urostealith,  calcium  car- 
bonate, fibrin  and  indigo 

The  changes  in  the  kidney  due  to  the  presence  of  calculi  vary  with  the 
irritation  which  they  cause,  their  size^  their  number  and  with  their  passage 
or  retention.  Numerous  stones  may  exist  in  the  calices  without  causing  any 
abnormal  condition  of  the  lining  of  the  pelvis;  on  the  other  hand  their  presence 
may  cause  turbidity  of  the  urine  and  desquamation  of  the  pelvic  epithelium. 
Gravel  may  be  passed  at  intervals  without  causing  symptoms  or  pelvic  lesions 
and  larger  stones  may  cause  successive  attacks  of  renal  colic  in  their  passage 
while  no  changes  take  place  in  the  kidney  or  its  pelvis.  Dendritic  calculi 
may  exist  in  the  pelvis  for  years  without  causing  inflammation  but  their  con- 
tinued presence  ultimately  results  in  induration  of  the  kidney.  Serious  con- 
sequences of  kidney  stone  are  pyelitis  and  pyonephrosis,  and  hydronephrosis 
may  be  caused  bv  the  impaction  of  a  calculus  in  the  ureter. 

Symptoms.     The  most  constant  symptom  of  calculus  in  the  kidney  is  pain 


NEPHROLITHIASIS.  713 

in  the  region  of  the  kidney;  with  this  is  associated,  in  greater  or  less  degree, 
tenderness.  The  pain  is  usually  referred  to  the  affected  kidney  but  some- 
times to  the  normal  side;  it  may  radiate  in  the  direction  of  the  course  of  the 
ureter  and  even  as  far  as  the  penis  or  scrotum;  it  is  increased  upon  motion. 
Hasmaturia  is  sometimes  present.  The  blood  is  seldom  of  large  amount  and 
may  be  absent  from  time  to  time;  it  is  increased  by  exercise  or  violent  motion 
of  any  kind.  A  small  number  of  pus  cells  is  frequently  present  in  the  urine 
even  if  true  pyelitis  does  not  exist;  mucus  and  the  brick  dust  crystals  of  uric 
acid  are  often  found;  calcium  oxalate  crystals  are  also  common.  The  reaction 
of  the  urine  is  alkaline  in  the  presence  of  phosphatic  calculi,  acid  with  those  of 
uric  acid,  while  with  calcium  oxalate  stone  the  reaction  may  be  acid,  alkaline 
or  neutral.  Complete  occlusion  of  the  ureter  by  a  calculus  results  in  hydrone- 
phrosis with  its  attendant  symptoms  (q.v.). 

Renal  colic  is  caused  by  the  entrance  of  a  stone  into  the  ureter  and  its  attempt 
to  force  a  passage.  Its  onset  may  be  sudden  without  assignable  cause  or  it 
may  follow  muscular  exertion.  It  is  evidenced  by  most  extreme  pain  begin- 
ning in  the  region  of  the  kidney  and  radiating  along  the  course  of  the  ureter 
to  the  groin,  inside  of  the  thigh,  or  testicle,  which  last  may  be  retracted.  More 
rarely  the  pain  extends  through  to  the  back  or  upward  to  the  diaphragm.  A 
chill  followed  by  a  considerable  rise  in  temperature  may  usher  in  the  attack. 
Nausea  and  vomiting  are  frequent  symptoms  and  localized  tenderness  may 
be  present;  cold,  clammy  sweat  may  break  out  upon  the  skin  and  a  condition 
of  collapse  may  ensue.  The  attack  may  last  from  an  hour  or  two  to  a  day 
or  more  and  ceases  when  the  calculus  has  reached  the  bladder.  In  the  pro- 
longed paroxysms  periods  of  intermission  are  common.  There  is  frequent 
passage  of  urine  which  usually  contains  blood.  Each  urination  as  a  rule 
is  small  in  quantity  but  at  times  clear  urine  may  be  voided  in  considerable 
amount  from  the  normal  kidney.  Suppression  of  urine  with  consequent 
urasmia  may  occur.  After  the  attack  there  is  more  or  less  localized  pain 
over  the  region  of  the  kidney  and  ureter,  and  the  testis  of  the  affected 
side  may  be  swollen  and  tender.  Intermittent  discomfort  in  the  lumbar 
region  may  remind  the  patient  for  months  afterward  of  his  paroxysm.  The 
stone  may  remain  in  the  bladder  or  be  passed  through  the  urethra.  Succes- 
sive attacks  often  are  observed  but  certain  patients  after  having  suffered  from 
one  never  experience  another. 

The  diagnosis.  The  condition  may  be  confounded  with  intestinal  or 
hepatic  colic;  in  most  instances,  however,  renal  colic  possesses  certain  char- 
acteristics, such  as  pain  radiating  down  the  ureter  to  the  testis,  retraction  of 
this  organ  and  the  characteristic  urine,  which  render  the  exclusion  of  the 
two  former  conditions  easy.  Intestinal  colic  is  likely  to  follow  errors  of  diet, 
the  pain  is  most  often  in  the  umbilical  region  and  there  are  associated  flatu- 
lence and  constipation.     In  hepatic  colic  there  is  likely  to  be  jaundice,  with 


714  DISEASES    OF    THE    URINARY    SYSTEM. 

clay-colored  stools  and  pigmented  urine  and  the  pain  is  usually  referred  to 
the  region  of  the  gall-bladder.  Vesical  calculus  when  causing  pain  which 
cannot  be  differentiated  from  that  of  ureteral  calculus,  may  be  diagnosticated 
either  by  means  of  the  "searcher"  or  the  cystoscope;  in  bladder  stone  the 
reaction  of  the  urine  is  usually  alkaline,  while  in  calculus  higher  in  the 
urinary  tract  is  commonly  acid.  Calcium  oxalate  calculi,  being  more  rough 
of  surface,  are  said  to  cause  a  more  severe  type  of  paroxysm  than  those  of 
uric  acid,  while  the  pain  of  phosphatic  stone  is  considered  to  be  even  more 
marked. 

A  most  important  aid,  and  one  never  to  be  neglected  in  doubtful  instances 
or  before  the  institution  of  surgical  measures,  is  examination  by  means  of  the 
Rontgen  ray.  Properly  taken  plates,  will,  with  hardly  an  exception,  prove 
the  presence  or  absence  of  a  stone  and  are  also  useful  in  locating  its  position. 
Fluoroscopic  examination  is  unsatisfactory  and  it  should  be  remembered 
that  the  skilled  eye  can  often  demonstrate  a  calculus  upon  a  plate  which  to 
the  untutored  appears  wholly  negative. 

The  prognosis.  While  a  single  attack  of  renal  colic  may  be  all  to  which 
the  patient  is  subjected,  more  frequently  others  will  ensue  and  the  continued 
irritation  of  the  kidney  and  its  pelvis  is  likely  to  result  in  a  suppurative  con- 
dition. Large  calculi  remain  permanently  in  the  pelvis  of  the  kidney  unless 
removed  by  operation.  Fatal  attacks  of  renal  colic  have  been  reported. 
Under  the  present  day  surgical  treatment  of  kidney  stone  the  prognosis  has 
become  far  more  favorable  than  previously. 

Treatment.  As  a  prophylactic  measure  all  persons  possessing  the  so-called 
uric  acid  or  purinasmic  tendency  should  be  subjected  to  the  dietetic  and  other 
measures  suggested  under  the  treatment  of  purinaemia  (see  p.  263);  that  is  to 
say  the  nitrogenous  elements  of  the  diet  shovdd  be  to  a  considerable  degree 
restricted  and  for  them  carbohydrates  should  be  substituted.  The  urine 
should  be  kept  abundant  in  amount  and  its  acidity  should  be  diminished  by 
the  free  drinking  of  any  pure  water.  The  much  exploited  alkaline  and  lithia 
waters  are  probably  in  no  way  superior  to  ordinary  pure  distilled  water  but 
it  is  often  wise  to  prescribe  them  since  the  patient  will  take  a  prescribed  daily 
amount  of  a  named  and  supposedly  medicinal  water  when  he  will  wholly 
neglect  his  physician's  advice  if  the  agent  prescribed  is  nothing  more  than 
the  fluid  which  flows  from  the  tap  of  his  kitchen  sink.  Any  of  the  various 
"lithia"  waters  is  to  be  recommended  since  these  are  usually  pure.  Likewise 
the  patient  who  wiU  not  drink  a  sufficient  quantity  of  plain  water  will  often 
take  it  contentedly  if  advised  to  add  to  each  glass  10  grains  (0.66)  of  lithium 
carbonate  or  citrate.  The  quantity  of  water  advisable  for  these  cases  is  from 
I  to  2  quarts  (i  to  2  litres)  daily.  The  diuretic  and  antacid  effect  of  the  water 
may  be  augmented  by  taking  in  addition  15  to  20  minims  (i.o  to  1.33)  of 
liquor  potassae  well  diluted,  potassium  citrate,  20  grains  (1.33),  or  potassium 


NEPHROLITHIASIS.  715 

bicarbonate,  20  to  30  grains  (1.33  to  2.0),  three  times  a  day.  The  possibility  of 
rendering  the  urine  so  alkaline  as  to  predispose  to  the  formation  of  phosphatic 
calculi  must  not  be  forgotten,  for  calculi  composed  of  phosphates  about  a 
nucleus  of  uric  acid  have  been  observed.  Consequently  the  urine  should  be 
frequently  examined  and  the  appearance  of  an  excessive  alkalinity  should  be 
considered  a  signal  for  a  diminution  or  an  intermission  of  the  measures 
which  have  brought  about  this  state. 

The  employment  of  calcium  carbonate  in  doses  of  from  x  to  xx  grains  (0.66 
to  1.33)  three  times  a  day  has  recently  been  advocated  upon  the  hypothesis 
that  the  combination  of  the  calcium  with  the  acid  phosphates  in  the  alimentary 
tract  diminishes  the  deutero-phosphates  of  the  urine  with  the  result  that  the 
proto-phosphates  remain  to  dissolve  the  viric  acid. 

Calcium  oxalate  calculi  should  be  treated  both  dietetically  and  medicinally 
along  the  same  lines  as  those  advised  for  uric  acid  stone  but  in  phosphatic 
calculi  a  different  mode  of  treatment  is  necessary.  Here  the  problem  is  to 
render  the  urine  acid  and  the  best  means  of  accomplishing  this  object  is  by 
the  employment  of  a  diet  directly  the  opposite  of  that  indicated  in  hyperacid 
conditions.  The  food  should  be  chiefly  of  meat  and  the  carbohydrate  ele- 
ments should  be  restricted.  The  urine  should  be  kept  diluted  and  increased 
in  quantity  by  the  free  use  of  a  water  not  alkaline.  The  most  serviceable 
drugs  in  rendering  the  urine  acid  are  benzoic  acid  and  its  sodium  and  ammo- 
nium salts;  the  latter  are  preferable  because  of  their  greater  solubility.  The 
dose  of  either  is  from  10  to  15  grains  (0.66  to  i.o).  Boric  acid  also  will  render 
an  alkaline  urine  acid  and  is  most  effective  when  employed  as  potassium  tar- 
traborate;  its  dose  is  20  grains  (1.33)  three  or  four  times  daily  diluted  in  a  large 
amount  of  water.  Its  taste  may  be  disguised  with  licorice  or  syrup  of  orange  peel. 

The  so-called  uric  acid  solvents,  piperazin,  lysidin,  lycetol,  etc.,  may  be 
given  in  the  hope  of  dissolving  already  formed  calculi  but,  while  these  drugs 
may  succeed  in  dissolving  uric  acid  in  the  test-tube,  it  is  doubtfiil  if  they  possess 
any  distinctly  solvent  action  over  uric  acid  in  the  kidney  or  its  pelvis.  Piper- 
azin may  be  given  in  doses  of  7J  to  15  grains  (0.5  to  i.o)  three  times  a  day 
in  water,  plain  or  carbonated;  its  marked  hygroscopic  properties  prevent  its 
administration  in  pill  or  powder.  Lysidin  may  be  taken  in  doses  of  ^  to  2^ 
drachms  (2.0  to  lo.o)  of  the  50  percent,  alkaline  solution  in  a  glassful  of  car- 
bonated water.  The  dose  of  lycetol  (dimethyl-piperazin  tartrate)  is  from  5 
to  10  grains  (0.33  to  0.66)  three  times  a  day  in  carbonated  water  or  lemonade. 

Hexamethylenamine  is  considered  to  have  a  certain  amount  of  lithontriptic 
effect.  It  certainly  is  the  most  effective  urinary  antiseptic  which  we  possess; 
it  is  particularly  indicated  in  patients  with  phosphatic  calculi  and  alkaline 
urine  but  is  beneficial  as  well  in  the  other  varieties  of  stone.  Given  in  com- 
bination with  sodium  benzoate — hexamethylenamine  gr.  viiss  (0.5),  sodium 
benzoate  gr.  x  (0.66) — it  will  tend  to  render  the  urinary  tract  antiseptic,  and 


7l6  DISEASES    OF    THE    URINARY    SYSTEM. 

may  relieve  the  pain  in  the  region  of  the  kidney,  which  is  a  frequent  accompani- 
ment of  renal  stone. 

The  pain  of  an  attack  of  renal  colic  can  usually  be  controlled  by  nothing 
less  potent  than  a  considerable  dose  of  morphine — at  least  \  grain  (0.016) 
given  hypodermatically  and  repeated  if  necessary.  Suppositories  containing 
each  I  grain  to  i^  grains  (0.065  to  o.i)  of  powdered  opium  and  ^  to  ^  grain 
(0.016  to  0.032)  of  extract  of  belladonna  are  also  useful.  For  the  very  severe 
paroxysms  it  may  be  necessary  to  give  chloroform  by  inhalation  until  the  effect 
of  the  morphine  has  taken  place.  In  certain  instances  the  coal  tar  analgesics, 
antipyrine  sahcylate  (sahpyrine)  or  acetphenetidine  (phenacetine)  in  10 
grain  (0.66)  doses  will  relieve  the  pain  to  some  extent  and  almost  always  the 
employment  of  hot  compresses  or  poultices  of  flax-seed  are  of  benefit;  these 
and  hot  bathing  may  relax  the  ureteral  spasm  and  render  the  passage  of  the 
stone  more  easy.  Hot  drinks,  such  as  lemonade,  arroviroot  gruel,  etc.,  are 
frequently  grateful  to  the  patient  and  changes  in  position,  such  as  lowering 
the  head  and  raising  the  buttocks,  at  times  afford  a  certain  amount  of  relief. 

When  the  calculus  has  reached  the  bladder  the  agonizing  pain  disappears. 
The  stone  now  is  usually  passed  through  the  urethra  or  it  may  remain  in  the 
bladder  to  increase  in  size  as  a  vesical  calculus. 

In  nephrolithiasis,  operation  and  extraction  of  the  stone  is  necessary  if  the 
latter  is  too  large  to  enter  the  ureter,  becomes  impacted  during  its  passage, 
or  if  any  suppurative  process  is  present. 

NEOPLASMS  OF  THE  KIDNEY. 

The  kidney  may  be  the  seat  of  tumorous  growth  of  either  benign  or  malig- 
nant type.  Of  the  former  the  fibroma  is  the  most  common;  this  neoplasm 
is  usually  small  and  even  when  multiple  may  not  appreciably  increase  the 
size  of  the  organ.  Other  benign  tumors  which  may  involve  the  kidney  are  the 
lipoma,  the  angioma,  the  adenoma  and  the  villous  papilloma  which  may  have 
its  origin  in  the  pelvis  of  the  organ.  Cystic  tumors  are  frequent  and  will 
be  discussed  in  a  separate  section.     Gumma  of  the  kidney  may  also  occur. 

Malignant  neoplasms  of  the  kidney  are  of  two  varieties — carcinoma  and 
sarcoma.  The  latter  is  the  more  frequent  and  is  met  in  one  of  two  forms,  the 
alveolar  sarcoma  and  the  rhabdomyoma;  renal  sarcoma  is  often  observed  in 
children.  Malignant  tumor  of  the  suprarenal  body — hypernephroma — often 
involves  the  kidney  itself  as  well,  and  it  is  probable  that  in  many  instances 
apparently  primary  malignant  tumors  of  the  kidney  are  in  reality  primary 
in  the  suprarenal  capsule  and  secondary  in  the  former  organ. 

The  malignant  new  growths  may  become  so  large  as  to  nearly  fill  the  abdom- 
inal cavity,  they  usually  increase  in  size  rapidly  and  are  often  the  seat  of 
haemorrhage. 


NEOPLASMS    OF    THE    KIDNEY,  ']!'] 

Symptoms.  The  smaller  benign  tumors  often  give  no  symptoms;  one  of 
the  most  typical  symptoms  of  malignant  disease  of  the  kidney  is  haematuria, 
it  is,  however,  by  no  means  constant.  The  blood  may  be  either  fluid  or 
clotted  and  it  may  appear  in  the  form  of  casts  of  the  renal  pelvis  or  ureter. 
Blood  is  more  common  in  the  urine  of  carcinoma  than  in  that  of  sarcoma; 
rarely  the  urine  may  contain  fragments  of  the  growths  from  which  the  diag- 
nosis may  be  made. 

Pain  is  present  in  certain  instances  but  by  no  means  in  all.  In  character 
it  may  be  a  dull  ache  in  the  region  of  the  kidney  or  it  may  be  referred  to  the 
hip,  thigh  or  knee  because  of  the  pressure  of  the  growth  on  branches  of  the 
lumbar  plexus.  Pressure  upon  and  erosion  of  the  vertebrae  cause  severe 
pain  and  the  passage  of  clots  of  blood  tlirough  the  ureter  is  often  attended 
with  symptoms  suggestive  of  renal  colic,  the  pain,  however,  is  rather  less 
marked.  Progressive  emaciation  with  ultimate  cancerous  cachexia  is  fre- 
quent although  in  some  instances  the  patient's  nutrition  may  remain  in  good 
condition. 

Physical  Signs.  Bimanual  palpation  usually  detects  the  presence  in  the 
region  of  the  kidney  of  a  tumor  which  is  not  movable  from  side  to  side  but 
moves  in  a  vertical  direction  with  respiration,  though  less  so  than  do  growths 
involving  the  liver.  In  consistence  the  tumor  may  be  firm  or,  if  of  rapid 
growth,  soft.  In  children  the  enlargement  of  the  abdomen  is  often  marked 
and  the  superficial  veins  are  dilated.  The  hand  may  be  able  to  insert  itself 
between  the  tumor  and  the  liver  on  the  right  side  and  between  it  and  the 
spleen  on  the  left;  early  in  the  disease  tympany  may  be  elicited  upon  percus- 
sion of  this  space  but  later  this  is  likely  to  become  impossible.  Renal  neo- 
plasms enlarge  anteriorly  rather  than  backward  and  push  forward  the  colon, 
the  presence  of  which  between  the  growth  and  the  abdominal  wall,  as  evidenced 
by  obtaining  a  tympanitic  note  upon  percussion,  is  an  important  point  in 
the  differentiation  of  tumors  of  the  kidney  from  those  of  neighboring  organs. 

The  differential  diagnosis  of  sarcoma  from  carcinoma  may  be  based 
upon  the  following  points:  the  former  is  more  common  and  is  most  frequently 
seen  in  young  children  while  carcinoma  is  usually  observed  in  later  life. 
In  the  latter  the  emaciation  is  more  rapid,  haematuria  is  more  common  and 
metastatic  growths  are  often  observed. 

Tumors  of  the  kidney  may  be  differentiated  from  ovarian  tumors  by  the 
more  frequent  occurrence  of  iirinary  changes  and  by  the  fact  that  the  colon 
is  usually  demonstrable  between  the  growth  and  the  abdominal  wall,  while 
in  the  latter  condition  there  is  tympany  in  the  flanks,  the  intestines  being  in 
this  region,  the  tumor  grows  upward  from  below,  there  are  often  symptoms 
referable  to  the  genital  tract  and  rectal  and  vaginal  examination  reveals  gen- 
ital abnormalities. 

The  tumor  of  retroperitonasal   glandular  enlargement   is  not   associated 


7l8  DISEASES    OF    THE    URINARY    SYSTEM. 

with  urinary  symptoms  and  the  growth  is  central  instead  of  being  rather  upon 
one  side.  A  confusing  sign  may  be  the  presence  of  tympany  upon  percussion 
due  to  the  position  of  the  intestines  in  front  of  the  tumor. 

Hepatic  tumors  move  more  freely  during  respiration  than  do  those  of  the 
kidney;  there  is  often  prominence  of  the  right  hypochondriac  region  and  the 
edge  of  the  liver   is  often   palpable. 

Enlargements  of  the  spleen  move  freely  with  the  descent  of  the  diaphragm 
and  the  tumor  extends  downward  from  above;  its  edge  is  palpable  and  the 
marginal  notch  may  be  demonstrated.  The  growth  is  in  contact,  as  a  rule, 
with  the  abdominal  parietes  and  consequently  percussion  yields  a  dull  note. 

The  prognosis  is  unfavorable  even  if  the  tumor  is  removed  while  still  small 
and  before  the  incidence  of  metastases.  Sarcoma  is  usually  fatal  within 
a  few  months  while  in  carcinoma  life  may  be  prolonged  for  a  more  extended 
period. 

Treatment,  aside  from  radical  surgical  measures,  consists  merely  in  render- 
ing the  patient  as  comfortable  as  possible  by  the  employment  of  hypnotics 
when  necessary  and  in  the  administration  of  tonics  and  a  nutritious  diet  in 
order  that  bodily  strength  may  be  maintained  as  long  as  possible. 

THE  CYSTIC  KIDNEY. 

Cysts  of  the  kidney  may  be  either  congenital  or  acquired;  in  the  congeni- 
tally  cystic  kidney  the  condition  is  usually  bilateral,,  the  affected  organ  con- 
taining a  number  of  rounded  cysts  ranging  in  size  from  that  of  a  small  pea  to 
that  of  a  hen's  egg.  The  enclosed  fluid  may  be  clear  or  turbid,  brownish-red 
or  dark  brown  in  color,  acid  in  reaction,  and  it  contains  albumin,  urinary  salts, 
blood  and  more  rarely  uric  acid  and  urea.  Usually  this  affection  results 
in  early  death,  but  in  infrequent  instances  adult  life  may  be  reached  and 
the  condition  has  been  found  at  autopsy,  having  given  no  symptoms  intra 
vitam.     Large  foetal  cystic  kidneys  may  cause  obstruction  to  labor. 

Acquired  cysts  of  the  kidney  are  of  various  types: 

a.  Retention  cysts.  These  are  usually  small  and  contain  fluid  which 
has  once  been  urine  but  has  become  watery;  it  may  contain  albumin  and 
traces  of  the  urinary  solids.  This  condition  is  observed  in  chronic  nephritis  as 
a  result  of  stenosis  of  the  tubules  by  the  increased  connective  tissue.  Large 
cysts  have  been  observed  in  kidneys  which  present  no  other  abnormality. 
These  may  contain  blood  and  probably  are  also  to  be  classed  in  this  group. 

b.  Dermoid  cysts  of  the  kidney  have  been  reported.  These  may  occur 
in  otherwise  healthy  kidneys. 

c.  Hydronephrotic  cysts.  Hydronephrosis  in  which  pressure  has  reduced 
the  kidney  to  a  mere  shell  (see  p.  708)  may  be  classed  among  the  cystic  con- 
ditions affecting  this  organ. 

d.  Renal  cysts  occurring  with  a  cystic  condition  of  other  organs,  partic- 


IDIOPATHIC    HEMATURIA.  719 

ularly  the  liver,  spleen  and  thyroid  gland.  This  form  of  cystic  disease  is, 
in  all  likelihood,  the  result  of  defective  development. 

e.  Hydatid  cyst  of  the  kidney  is  seldom  observed.  The  diagnosis  is  made 
upon  the  demonstration  of  hooklets  or  bits  of  the  cyst  wall  in  the  urine  and 
upon  associated  hydatid  disease  of  other  organs.  Hydronephrosis  may 
result  from  ureteral  obstruction  due  to  the  attempt  to  pass  these  fragments. 

Symptoms.  These  consist  of  the  presence  of  a  tumor  in  the  renal  region, 
the  physical  signs  and  differential  diagnosis  of  which  have  been  discussed 
in  the  section  upon  renal  neoplasms  (p.  717);  of  hasmaturia  which  is  usually 
intermittent  and,  in  instances  of  cysts  due  to  obstruction  of  the  tubules  by  the 
interstitial  growth  of  a  chronic  nephritis,  the  symptoms  of  this  primary  condi- 
tion, such  as  heightened  arterial  tension,  arteriosclerosis,  cardiac  hyper- 
trophy, a  urine  increased  in  amount,  of  low  specific  gravity  and  urea  content, 
and  containing  albumin  and  casts,  are  present. 

The  physical  signs  are  those  of  tumors  of  the  kidney  (p.  717)  and  of  hydrone- 
phrosis (see  p.  709). 

The  diagnosis  is  based  upon  the  same  general  points  as  that  of  tumor. 

The  prognosis  in  double  cystic  kidney  is  unfavorable,  operation  being 
out  of  the  question,  and  the  probability  of  uraemia  or  heart  failure,  especially 
when  the  cysts  occur  in  chronic  nephritis,  being  great.  Unilateral  cystic 
disease  is  amenable  to  cure  by  operation  and  the  possibility  of  rupture  of  a 
cyst  and  consequent  perinephritis  or  peritonitis  is  not  to  be  forgotten. 

Treatment,  aside  from  the  relief  of  pain,  maintenance  of  the  patient's  nutri- 
tion and  the  management  of  the  chronic  nephritis,  if  this  is  present,  is  wholly 
within  the  province  of  the  surgeon.  The  operation  should  be  adapted  to  the 
condition  in  hand,  it  being  possible  to  enucleate  single  cysts  without  removal 
of  the  kidney.     Nephrectomy  may  be  performed  when  this  is  impossible. 

IDIOPATHIC  HEMATURIA. 

Synonyms.     Renal  Epistaxis;   Unilateral  Renal  Haemorrhage. 

Definition.  Blood  appearing  in  the  urine  from  unknown  cause.  The 
condition  is  not  a  very  frequent  one  and  is  to  be  distinguished  from  the  haema- 
turia  of  the  kidney  lesions  previously  described,  from  malarial  haematuria 
and  from  renal  haemorrhage  occurring  in  anaemia,  leukaemia  and  other  diseases 
of  the  blood,  from  that  of  traumatism  and  that  of  parasitic  disease. 

Symptoms.  Of  these  the  most  characteristic  is  the  appearance  of  blood 
in  the  urine.  The  blood  is  seldom  passed  in  clots  but  is  usually  mixed  with 
the  urine,  which  is  acid  and  of  smoky  tinge  when  passed,  becoming  brighter 
red  as  alkaline  fermentation  takes  place.  Albumin  is  present  in  quantity 
varying  with  the  amount  of  blood,  and  red  blood  cells,  leucocytes  and  blood 
casts  are  demonstrable  by  the  use  of  the  microscope. 


720  DISEASES    OF    THE    URINARY    SYSTEM. 

In  typical  instances  no  other  symptoms  are  present,  although  there  may  be 
complaint  of  lumbar  pain.  With  the  persistence  of  the  haemorrhage,  pro- 
gressive weakness  ensues.  The  condition  may  be  associated  with  renal 
displacement,  pelvic  lesions  and  destructive  changes  in  the  kidney. 

Treatment  consists  chiefly  in  the  insistence  upon  rest  in  bed  and  the  appli- 
cation of  cold  to  the  lumbar  region,  together  with  the  administration  of  agents 
which  increase  the  coagulability  of  the  blood  and  of  astringents.  Of  the 
former  the  most  effective  is  calcium  lactate  which  may  be  given  in  doses  of 
20  to  30  grains  (1.33  to  2.0)  three  times  a  day.  Rather  less  efficient  is  calcium 
chloride  20  grains  (1.33)  three  times  daily.  Gelatin  also  has  a  certain  action  in 
the  increase  of  the  blood's  coagulability  and  it  may  be  given  both  hypoder- 
matically  and  by  mouth.  For  purposes  of  subcutaneous  administration  2^ 
percent,  of  purified  gelatin  is  dissolved  in  normal  saline  solution;  of  this  an 
ounce  (30.0)  or  more  may  be  injected  at  a  time.  The  gelatin  when  given 
internally  maybe  prescribed  in  the  following  formula:  Pure  gelatin  5  to  10  parts, 
distilled  water  150  parts,  simple  syrup  25  parts;  of  this  a  dessert  spoonful  (8.0) 
is  to  be  given  every  two  hours.  It  may  be  taken,  if  necessary,  in  larger  quantity 
and  prescribed  in  10  percent,  solution  of  which  a  pint  (500.0)  may  be  taken 
daily.  Ergot  in  the  form  of  ergotine  injected  under  the  skin  in  doses  of  5  to 
10  grains  (0.33  to  0.66)  or  given  by  mouth  in  similar  dose  may  be  employed. 
Astringents,  such  as  lead  acetate,  alum,  gallic  and  tannic  acids,  catechu, 
hamamelis  virginica,  and  iron  persulphate  may  be  tried  but  little  is  to  be 
expected  of  them.     Electric  baths  may  benefit  the  patient. 

The  diet  should  be  chiefly  of  milk.  Demulcent  and  acidulated  drinks 
may  be  permitted. 

HEMOGLOBINURIA. 

Definition.  A  condition  in  which  blood-pigment  appears  in  the  urine 
The  coloring  matter  may  be  either  haemoglobin  or  methaemoglobin  and  may 
be  associated  with  the  presence  of  a  few  red  blood  cells  either  intact  or  in  a 
state  of  disintegration.  Hsemoglobinuric  urine  is  reddish-brown  or  black 
in  color  if  the  pigment  is  present  in  considerable  amount;  if  only  in  small 
quantity  the  urine  is  smoky.  Upon  standing  a  heavy  brown  sediment  is 
deposited.  Albumin  is  present  and  the  use  of  the  microscope  reveals  the 
presence  of  blood  cells,  epithelial  cells,  urates  and  pigment  granules.  Spectro- 
scopic examination  detects  the  bands  of  absorption  which  characterize  the 
spectrum  of  oxyhasmoglobin  or  that  of  methaemoglobin.  In  the  former 
instance,  which  is  more  infrequent  than  the  latter,  the  bands  are  two  in 
number.  The  spectrum  of  methaemoglobin  exhibits  three  bands,  that  ia 
the  red  near  C  being  typical. 

Haemoglobinuria,  clinically,  may  be  divided  into  two  separate  varieties. 


TOXIC    HEMOGLOBINURIA.  72 1 

TOXIC  HEMOGLOBINURIA. 

This  type  of  haemoglobinuria  is  caused  by  the  presence  in  the  organism  of 
poisonous  substances  which  separate  the  haemoglobin  from  the  red  cells. 
Such  poisons  are  phenol,  pyrogallic  acid,  sulphuretted  and  arsenuretted  hydro- 
gen, carbon  monoxide,  naphthol,  nitrobenzol,  potassium  chlorate  and  the 
toxic  substances  contained  in  mushrooms.  It  also  occurs  as  a  result  of  the 
presence  of  the  toxins  of  the  infectious  diseases  such  as  enteric  fever,  scarla- 
tina, yellow  fever,  syphilis  and  especially  malaria  (blackwater  fever),  and  has 
been  observed  after  excessive  muscular  exertion,  exposure,  severe  burns  and 
during  pregnancy.  The  transfusion  of  blood  from  one  mammal  to  another 
results  in  haemoglobinuria  and  finally,  a  form  of  this  condition  may  be  met 
in  newly-born  infants  where  it  is  accompanied  by  cerebral  symptoms,  venous 
congestion  and  jaundice. 

The  prognosis  is  usually  favorable  but  is  dependent  upon  the  cause  and 
the   severity  of   the   accompanying  symptoms. 

PAROXYSMAL  HEMOGLOBINURIA. 

This  is  a  rare  condition  occurring  usually  in  adults  and  more  frequently  in 
men  than  in  women.  The  attacks  appear  at  intervals,  are  of  sudden  onset 
and  are  characterized  by  the  passage  of  urine  containing  blood  pigment. 
Chilly  feelings,  fever,  and  general  pains  may  be  associated  with  the  paroxysm 
which  rarely  lasts  more  than  a  day.  Several  attacks  in  the  course  of  a  day 
have  been  observed.  Nausea  and  vomiting  and  lumbar  pain  may  character- 
ize the  seizure  and  at  times  the  temperature  is  subnormal.  As  causes,  exposure 
to  cold  and  wet,  excesssivc  muscular  exertion  and  malaria  may  be  mentioned. 
Individuals  suffering  from  Raynaud's  disease  may  be  subject  to  hsmoglo- 
binuric  attacks  but  the  association  of  the  two  conditions  has  not  been 
satisfactorily  explained. 

An  associated  symptom  is  jaundice  and  the  condition  is  always  preceded 
by  the  appearance  of  free  haemoglobin  in  the  blood  (haemoglobinJEmia). 

No  satisfactory  explanation  of  the  pathogenesis  of  haemoglobinuria  has 
yet  been  advanced;  the  best  manner  in  which  we  can  at  present  account  for 
the  condition  is  to  say  that  in  some  fashion  an  increased  haemolysis  is  brought 
about  and  the  resulting  haemoglobin  is  dissolved  in  the  fluid  elements  of  the 
blood  and  later  appears  in  the  urine. 

The  prognosis  is  favorable  as  a  rule  but  the  paroxysms  may  persist  for 
considerable  periods. 

Treatment.  Prevention,  in  both  forms  of  haemoglobinuria  consists  in  the 
avoidance  of  exposure  and  of  over-exertion.  Upon  removal  to  a  warm  climate 
the  frequency  of  the  attacks  becomes  much  reduced.  In  the  treatment  of 
the  condition  itself  we  should  endeavor  to  eliminate  the  causal  factor  by 
stopping  the  ingestion  and  aiding  the  elimination  of  poisons  and  by  proper 
46 


72  2  DISEASES   OF   THE    URINARY    SYSTEM. 

treatment  of  any  infectious  condition  which  may  be  present.  If  the  haemo- 
globinuria  is  the  result  of  syphilis,  mercury  and  the  iodides  should  be  pre- 
scribed; if  it  is  due  to  malarial  poisoning,  quinine  should  be  ordered.  The 
latter  drug  should  be  given  with  caution  since  it  is  said  to  increase  the  tendency 
to  haemoglobinuria  in  some  instances.  The  attack  itself  may  sometimes 
be  aborted  or  shortened  by  means  of  inhalations  of  amyl  nitrite.  During 
the  seizure  the  patient  should  be  kept  in  bed  and  warmly  covered;  he  should 
be  protected  from  draughts  and  may  be  given  hot  drinks.  The  employment 
of  astringents  and  of  other  means  suited  to  the  treatment  of  renal  haemor- 
rhage has  been  suggested. 

The  anaemia  secondary  to  the  destruction  of  the  red  blood  cells  necessitates 
the  administration  of  tonics,  iron  in  particular. 

CHYLURIA. 

Definition.  A  rare  condition  in  which  the  urine  is  mixed  with  minute 
droplets  of  fat  imparting  to  this  secretion  a  milky  appearance.  The  chyle 
varies  in  amount  from  a  quantity  so  small  as  to  render  the  urine  only  slightly 
opalescent  to  so  large  an  admixture  that  this  fluid  becomes  opaque,  white  and 
scarcely  to  be  distinguished  by  its  appearance  from  milk.  With  the  chyle, 
blood  is  often  present  and  the  latter,  upon  allowing  the  urine  to  stand,  may 
form  a  clot  at  the  bottom  of  the  vessel  while  the  former  rises  to  the  surface, 
forming  a  creamy  layer.  Microscopical  examination  reveals  the  presence  of 
red  blood  cells  in  varying  number  and  of  granular  fatty  matter;  more  seldom 
the  fat  may  be  visible  in  droplets  as  in  milk. 

.Etiology.  The  most  usual  cause  of  chyluria  is  the  parasitic  disease  due 
to  the  filaria  sanguinis  hominis  or  filaria  Bancrofti  (see  the  section  upon  para- 
sitic diseases)  but  even  in  this  affection  chyle  is  not  always  present  in  the 
urine.  Other  instances  of  chyluria  are  difficult  of  explanation  but  must 
occur  as  a  result  of  a  communication  between  the  chyle  vessels  and  the  urinary 
tract,  although  this  condition  has  not  been  reported  as  a  post  mortem  finding. 
Certain  it  is,  however,  that  chyluria  may  exist  when  careful  blood  examina- 
tion during  Hfe  and  thorough  search  after  death  reveal  the  presence  of  no 
embryo  filariae  or  eggs. 

Symptoms  other  than  the  condition  of  the  urine,  which  contains  chyle  con- 
stantly or  intermittently,  are  usually  wanting.  In  certain  instances  there  is  loss 
of  flesh  and  strength,  lumbar  pain  or  occasional  discomfort  in  urination  resvilting 
from  obstruction  to  the  passage  of  coagulated  material  through  the  urethra. 

The  prognosis  as  to  life  is  favorable  but  the  passage  of  chyle  in  the  urine 
may  persist  continuously  or  intermittently  for  years.  In  some  instances 
it   may   cease   spontaneously. 

Treatment  consists  merely  in  making  the  patient  as  comfortable  as  possible 
and  in  the  employment  of  measures  calculated  to  maintain  nutrition. 


INDIC  ANURIA.  723 

INDICANURIA. 

Definition.  A  condition  characterized  by  the  presence  of  indican  (indoxyl- 
potassium-sulphate)  in  the  urine.  The  presence  of  this  substance  may  be 
proven  by  the  employment  of  Obermeyer's  test  or  others  of  like  character. 
Of  these  perhaps  the  simplest  is  the  following:  To  a  few  drops  of  5  percent, 
aqueous  solution  of  ferric  chloride  in  a  test  tube  add  about  5  c.c.  each  of  hydro- 
chloric acid  and  urine;  shake  and  allow  to  stand  for  about  ten  minutes;  add 
about  2  c.c.  of  chloroform,  shake  again  and  allow  the  chloroform  to  settle 
to  the  bottom  of  the  tube.  If  indican  is  present  the  chloroform  will  take  a 
more  or  less  intense  blue  tinge.  (For  more  elaborate  tests  the  reader  is  re- 
ferred to  works  upon  laboratory  diagnosis.) 

Etiology.  In  the  majority  of  instances  the  presence  of  indicanuria  signi- 
fies the  absorption  of  indol  from  the  alimentary  tract.  When  it  is  not  due  to 
this  cause  the  existence  of  an  abscess  somewhere  in  the  body  or  that  of  a  dead 
foetus  may  account  for  its  appearance.  Indicanuria  being  merely  a  symp- 
tom of  the  presence  of  indol  in  the  intestine,  it  behooves  us  to  consider  this 
substance  for  a  moment.  Indol  is  a  product  of  the  putrefactive  decomposi- 
tion of  proteid  bodies  and  it  is  formed  in  the  colon  during  the  course  of  putre- 
factive processes  occurring  within  this  viscus;  from  this  situation  indol  is 
absorbed  and  is  excreted  by  means  of  the  urine  in  the  form  of  indican. 

In  the  human  intestine  indol  is  formed  by  the  action  of  living  micro-organ- 
isms upon  proteid  material,  possibly  with  the  aid  of  the  processes  of  digestion, 
and  is  probably  responsible  for  various  toxic  conditions.  It  is  probable  that 
the  presence  of  free  indol  in  the  blood  may  depress  the  muscular  system  as  is 
shown  by  the  fatigue  which  appears  rapidly  in  some  individuals  who  have 
been  affected  with  marked  indicanuria  for  a  considerable  period.  Experi- 
ments have  shown  that  a  small  quantity  of  indol  acting  for  some  time  upon  a 
muscle  lessens  its  working  power.  This  fact  has  led  to  the  supposition  that 
certain  instances  of  myasthenia  gravis  in  which  indicanuria  is  present  may  be 
caused  by  the  presence  of  indol  or  some  kindred  substance  in  the  circulation. 

Normally  there  is  little  or  no  indican  in  the  urine  of  children  but  in  adults 
this  body  may  be  present  in  moderate  amount  for  considerable  lengths  of 
time  without  being  evidenced  by  any  associated  disturbance  of  health.  Even 
large  quantities  of  indican  may  occur  in  the  urine  at  intervals  but  in  individuals 
who  exhibit  this  phenomenon  there  is  usually  some  concomitant  disorder  of  the 
digestive  system  or  toxic  condition  of  other  type.  These  facts  may  appear 
puzzling  but  when  we  consider  that  certain  organisms  are  able  to  defend  them- 
selves against  the  poisonous  effects  of  indol,  while  others  are  less  fortunate, 
the  matter  is  explained,  at  least  to  some  extent.  The  cells  in  youth  possess 
far  more  power  to  oxidize  indol  than  in  age,  and  in  consequence  it  is 
likely  that  the  body  is  more  apt  to  suffer  from  the  absorption  of  a  given  amount 


y24  DISEASES    OF    THE    URINARY    SYSTEM. 

of  indol.  in  childhood  or  young  adult  life  than  in  middle  or  old  age,  even  put- 
ting out  of  the  question  the  presence  of  the  degenerations  of  the  organs  which 
often  exist  under  the  latter  conditions.  Thus  in  estimating  the  importance 
of  the  presence  of  indican  in  the  urine  of  a  given  patient,  we  must  consider 
his  age  and  whether  the  organs  are  in  a  state  of  degeneration. 

In  certain  subjects  constipation  has  a  marked  influence  upon  the  production 
of  indicanura,  but  children  and,  less  frequently,  adults  may  often  go  for  some 
days  without  defecating  and  exhibit  no  indican  in  the  urine;  this  fact  is 
difficult  of  explanation  but  it  is  probable  that  when  there  is  stagnation  of 
food  residue  in  the  colon  the  presence  in  this  viscus  of  undigested  proteid  is 
necessary  to  the  production  of  indol,  and  if  the  stoppage  of  the  food  remnants 
is  in  the  small  intestine  indol  is  not  produced  unless  colon  bacilli  or  other 
bacteria  which  are  able  to  make  indol  from  peptone  or  albumose,  are  present. 

Treatment.  In  view  of  the  causation  of  the  condition  under  considera- 
tion it  is  natural  to  hold  as  the  first  indication  a  thorough  cleansing  of  the 
intestine  by  means  of  catharsis.  Perl:kaps  as  simple  and  effectual  a  method 
as  any  of  relieving  the  burdened  digestive  tract  of  its  contents  is  the 
administration  of  repeated  fractional  doses  of  calomel,  to  be  followed  after 
some  hours  by  one  of  the  saline  purgative  waters.  The  continued  use  of 
cathartics  is  however  unadvisable.  (See  the  treatment  of  chronic  constipa- 
tion.) In  securing  intestinal  antisepsis,  which  we  should  endeavor  to  do 
after  thorough  purgation  has  taken  place,  the  most  effective  agents  at  our 
command  are  bismuth  tetraiodophthaleinate  and  bismuth  naphtholate;  of 
these  from  5  to  8  grains  (0.33  to  0.5)  may  be  given  three  times  daily.  Re- 
sorcinol  also  may  be  employed. 

Diet  regulation  is  most  important,  and  in  many  patients  the  indicanuria  may 
be  reduced  by  lessening  the  quantity  of  meat  in  the  regimen;  milk  may 
be  substituted  for  the  meat  in  many  instances  to  advantage.  When,  in  spite 
of  the  employment  of  a  milk  diet,  the  indicanuria  is  persistent,  especially  if 
the  patient  is  syphilitic  or  is  a  subject  of  arterial  degeneration,  the  adminis- 
tration of  potassium  iodide  may  bring  about  the  desired  effect  and  the  admin- 
istration of  iron,  particularly  liquor  ferri  et  ammonii  acetatis,  has  accomplished 
good  results  where  other  means  have  failed.  In  considering  the  diet  it  must 
be  remembered  that  the  carbohj^drates,  if  consumed  in  excess,  should  be  dimin- 
ished as  well  as  the  proteids.  When,  despite  regulation  of  both  the  carbohy- 
drate and  the  proteid  intake,  the  urine  continues  to  contain  indican,  jellies 
made  of  gelatin  (indol  is  not  formed  from  this  substance)  may  be  orescribed 
to  take  the  place  of  a  portion  of  the  necessary  proteid  food. 


ACUTE    ENCEPHALITIS.  725 


CHAPTER  X. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

DISEASES  INVOLVING  CHIEFLY  THE  BRAIN  AND  ITS 
MEMBRANES. 

ACUTE  ENCEPHALITIS. 

Synonym.     Acute  Cerebritis. 

Definition.     A  primary  acute  inflammation  of  the  cerebral  tissue. 

.Etiology.  Tliis  condition  is  the  result  of  microbic  infection.  It  is  predis- 
posed to  by  any  cause  which  lowers  the  body  resistance,  such  as  acute  alco- 
holism. As  a  primary  disease  it  seldom  if  ever  occurs  but  it  is  seen  in  most 
instances  as  a  complication  or  sequela  of  the  acute  infectious  diseases,  such 
as  scarlet  fever,  variola,  measles,  influenza,  infectious  endocarditis  or  other 
septic  conditions. 

Pathology.  The  portions  of  the  brain  most  often  involved  are  the  base, 
the  temporal  lobes  and  the  corpus  striatum.  There  is  intense  inflammation 
and  congestion  with  serous  exudation,  migration  of  leucocytes  and  minute 
hsemorrhages;  the  neighboring  cerebral  substance  may  become  softened. 
In  mild  cases  the  inflammatory  process  may  subside  with  absorption  of  the 
exudate  and  small  sclerosed  areas  may  result,  permanently  impairing  the 
brain  function.  In  cases  of  severe  type  the  areas  of  softening  and  the  haemor- 
rhages are  of  greater  extent. 

Symptoms.  The  onset  of  the  disease  is  usually  sudden,  with  headache, 
dizziness,  nausea,  vomiting  and  a  chill  followed  by  a  rise  in  temperature  to 
103°  to  105°  F.  (39.5°  to  40.5°  C).  The  pulse  and  respiration  are  accelerated 
and  symptoms  of  cerebral  irritation,  such  as  convulsions,  photophobia  and 
delirium,  may  occur;  later  these  disappear  and  the  patient  becomes  stuporous 
or  relapses  into  a  state  of  partial  coma  from  which  he  can,  however,  be 
aroused.  The  neck  is  not  stiff  nor  are  the  pupils  contracted.  The  patient 
may  lie  in  this  condition  for  a  number  of  days,  the  symptoms  may  abate  and 
gradually  disappear,  recovery  supervening,  or  he  may  relapse  into  a  state  of 
coma  and  finally  die. 

Focal  symptoms  depending  upon  the  part  of  the  brain  affected  are  common; 
these  may  be  paralyses  of  an  arm  or  leg,  hemipelgia,  hemianopsia,  aphasia, 
optic  paralysis,  nystagmus,  speech  disturbances,  etc. 

After  recovery  permanent  disabilities  of  brain  function  often  remain. 


726  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  prognosis  is  serious  but  by  no  means  do  all  instances  result  fatally 
or  in  permanent  cerebral  impairment. 

Treatment.  The  patient  should  be  confined  to  bed  in  a  darkened  room; 
the  bowels  should  be  moved  by  means  of  repeated  small  doses  of  calomel — 
gr.  J  (0.016) — or  a  saline.  Aconite,  in  doses  of  from  5  to  10  drops  (0.33- 
0.66)  every  two  to  four  hours,  should  be  given  to  lessen  the  fever  and  the  cir- 
culatory excitement.  An  ice  cap  should  be  applied  to  the  head  and  leeches 
to  the  nuchal  region  and  the  temples.  The  restlessness  may  be  relieved 
by  the  bromides  or  hydrated  chloral;  opium  and  morphine  seem  to  be  in- 
effectual. In  the  later  stages  cardiac  weakness  may  be  combated  by  the 
use  of  strychnine. 

During  convalescence  general  tonic  treatment  is  indicated  with  the  addition 
of  the  syrup  of  hydriodic  acid,  one  drachm  (4.0)  or  potassium  iodide,  gr.  x 
(0.66)  three  times  a  day  in  order,  if  possible,  to  aid  the  absorption  of  the  ex- 
udate and  lessen  the  tendency  to  sclerosis. 

The  diet  during  the  acuity  of  the  attack  should  be  entirely  fluid  and  feeding 
by  gavage  or  per  rectum  may  be  necessary. 

CEREBRAL  MENINGITIS. 

PACHYMENINGITIS. 

EXTERNAL  PACHYMENINGITIS. 

Definition.  An  inflammation  of  the  external  surface  of  the  dura  mater 
of  the  brain. 

.Etiology.  This  condition  results  from  necrosis  of  the  bones  of  the  skull, 
such  as  occurs  in  mastoid  or  middle  ear  disease,  in  chronic  nasal  inflamma- 
tions and  in  syphilis  of  the  cranial  bones.  It  may  also  follow  fractures  of 
the  skull  and  erysipelas. 

Symptoms.  These  are  often  obscvu^e;  there  are  usually  headache,  abnor- 
mally high  temperature,  delirium,  convulsions,  and  the  symptoms  of  increased 
intracranial  pressm-e  due  to  the  pressure  of  the  inflammatory  exudate.  This 
is  usually  piurulent  and  is  occasionally  of  sufficient  amount  to  cause  paralyses; 
in  severe  cases  the  infection  may  extend  to  the  pia  mater. 

Treatment  consists  in  the  proper  management  of  the  causative  factor  and 
in  the  relief  of  the  pressure  by  means  of  operation. 

INTERNAL  PACHYMENINGITIS. 

Synonyms.  Pachymeningitis  Hasmorrhagica;  Haematoma  of  the  Dura 
Mater. 

Definition.     An  inflammation  of  the  inner  surface  of  the  dura  characterized 


LEPTOMENINGITIS.  727 

by  the  production  of  new  tissue  which  is  rich  in  blood-vessels,  the  walls  of 
which  easily  rupture  with  resulting  haemorrhage. 

Etiology.  The  disease  is  rare;  it  is  seen  more  usually  in  males  of  middle 
age  or  over  but  occurs  occasionally  in  children.  The  chief  cause  seems  to 
be  chronic  alcoholism;  it  has  also  been  observed  in  insanity,  general  paralysis, 
after  the  acute  infectious  diseases,  in  tuberculosis  and  syphilis  and  associated 
in  mild  form  with  chronic  cardiac,  pulmonary  or  renal  conditions. 

Pathology.  The  inflammation  usually  begins  somewhere  in  the  distribution 
of  the  middle  meningeal  artery  as  a  congestion  and  extends  from  this  point; 
layers  of  false  membrane  are  formed  which  is  thickly  reticulated  with  dilated 
and  tortuous  blood-vessels,  the  walls  of  which  are  frequently  subject  to  rupture 
with  consequent  haemorrhage  varying  from  mere  traces  of  blood  to  extrava- 
sations of  considerable  size.  The  amount  of  blood  seen  on  necropsy  may  be 
greatly  in  excess  of  that  of  the  new-formed  tissue,  or  the  opposite  condition 
may  obtain;  both  the  new  tissue  and  the  extra vasated  blood  may  degenerate; 
in  the  former  the  blood-vessels  are  obliterated  and  the  blood  itself  becomes  de- 
colorized and  at  times  is  partly  absorbed.     Suppuration  is  a  rare  complication. 

Symptoms.  In  many  cases  these  are  obscured  by  the  co-existent  insanity 
or  mental  abnormality.  There  may  be  headache,  vomiting,  muscular  weak- 
ness and  signs  of  cerebral  compression  evidenced  by  convulsions,  nystagmus, 
stupor,  coma,  optic  neuritis,  or  partial  paralyses.  Seizures  resembling  apo- 
plexy may  occur  with  the  incidence  of  fresh  haemorrhagic  extravasations. 

The  prognosis  is  unfavorable  in  the  extreme. 

Treatment  consists  in  combating  the  symptoms  as  they  arise,  keeping  the 
patient  quiet  in  a  darkened  room,  elevating  the  head  and  in  the  application 
of  the  ice  helmet. 

Suppurative  and  pseudo-membranous  inflammations  of  the  internal  surface 
of  the  dura  resulting  from  injury,  from  extensions  of  adjacent  inflammatory 
conditions  and  as  complications  of  the  infectious  diseases  are  seen  but  their 
symptoms  are  so  obscure  as  to  prevent  their  recognition  during  life. 

LEPTOMENINGITIS. 

Definition.  An  inflammation  of  the  pia  mater  and  the  arachnoid  mem- 
brane characterized  by  an  exudation  between  these  two  structures. 

.Etiology.  The  disease  is  most  often  seen  in  young  children  and  as  a  com- 
plication of  the  acute  infectious  diseases,  pneumonia,  influenza,  smallpox, 
measles,  scarlatina,  enteric  fever,  and  septic  conditions.  The  exciting  cause 
is  a  pathogenic  micro-organism  of  almost  any  variety  which  obtains  entrance 
to  the  skull  by  means  of  the  blood  ciirrent,  as  a  result  of  diseases  of  the  cranial 
bones — for  instance  petrous  necrosis  following  otitis — through  the  cribriform 
plate  of  the  ethmoid  bone  or  through  any  other  opening  in  the  skull. 


728  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Pathology.  The  condition  may  be  localized  or  diffuse  and  affects  the 
basilar  portion  of  the  brain  more  often  than  the  convexity;  it  may  spread  to 
the  ventricles.  The  membranes  are  first  sw^ollen  and  hyperaemic,  then  cloudy 
in  appearance  and  finally  become  infiltrated  with  sero-purulent  or  purulent 
fluid.     The  process  may  spread  to  the  dura  mater  or  to  the  cerebrum  itself. 

SymptomSo  The  prodromata  of  this  condition  are  headache,  general 
malaise,  dizziness,  nausea  and  vomiting;  after  a  fev;^  days  signs  of  irritation 
appear,  such  as  a  continuance  of  the  headache  and  projectile  vomiting,  con- 
vulsions, an  irregular  temperature,  ioi°-io3°  F.  (38.5°-39.5°  C),  photophobia, 
unequal  and  contracted  pupils,  hyperaesthesia  of  the  skin,  retraction  of  the 
abdomen  and  stiffness  of  the  neck;  there  may  be  low  muttering  delirium  or 
alternating  delirium  and  stupor.  The  pulse  is  usually  irregular  and  weak, 
its  rate  may  be  slow  (60-70);  the  respiration  is  accelerated  and  irregular;  the 
bowels  are  constipated;  as  the  disease  progresses  the  symptoms  become  more 
marked,  there  may  be  general  rigidity  and  optic  neuritis.  As  the  stage  of 
paralysis  sets  in  the  pupils  become  dilated,  there  may  be  facial  paralysis, 
ptosis  or  strabismus,  the  abdomen  becomes  still  more  "boat-shaped,"  coma- 
is  present,  the  intestine  and  bladder  are  incontinent;  death  supervenes  within 
a  few  days  as  a  rule. 

Basilar  meningitis  is  characterized  by  paralyses  of  the  cranial  nerves,  optic 
neuritis  and  rigidity  of  the  neck,  while  if  the  inflammation  is  confined  to  the 
convexity,  the  delirium,  convulsions  and  paralyses  are  more  marked. 

The  diagnosis.  The  employment  of  lumbar  puncture  has  proved  a  great 
aid  in  the  diagnosis  of  this  condition.  The  character  of  the  fluid  withdrawn  by 
this  means  in  inflammations  due  to  other  causes  than  tuberciflosis,  is  purulent, 
although  pus  in  the  latter  case  may  sometimes  be  withdrawn.  The  only 
pathological  condition  in  which  the  fluid  remains  clear  is  tuberculosis;  the 
existence  of  disintegrated  blood  is  evidence  in  favor  of  pachymeningitis  or 
trauma,  while  fresh  blood  appears  as  a  result  of  the  passage  of  the  needle 
through  the  tissues  of  the  back.  Cytological  and  bacteriological  examination 
of  the  fluid  throws  further  light  upon  the  cause  of  the  process.  The  fluid 
may  be  strained  after  centrifuging  or  cultures  may  be  made.  The  finding  of 
the  bacillus  tuberculosis  settles  the  diagnosis,  but  failure  to  isolate  does  not 
disprove  the  possibility  of  this  organism  as  the  causative  factor. 

Other  micro-organisms,  such  as  the  pneumococcus,  staphylococcus,  strep- 
tococcus, etc.,  may  be  found.  A  differential  estimation  of  the  leucocytes  con- 
tained in  the  fluid  is  useful;  the  mononuclear  lymphocytes  are  usually  rela- 
tively increased  in  tuberculous  conditions  while  in  inflammations  due  to  other 
causes  there  is  likely  to  be  a  preponderance  of  the  polymorphonuclear  leuco- 
cytes. Normal  cerebrospinal  fluid  contains  a  small  amount  of  sugar  while 
inflammatory  exudates  are  free  from  this  substance. 

The  prognosis.     The  disease  lasts  from  a  few  days  in  very  acute  instances 


TUBERCULOUS    MENINGITIS.  729 

to  several  weeks  in  those  of  slower  course.  The  prognosis  is  grave  at  best 
but  not  necessarily  entirely  unfavorable. 

Treatment.  Prophylaxis  consists  in  the  antiseptic  treatment  of  cranial 
injuries  and  early  operation  with  proper  after-treatment  of  otitic  con- 
ditions. Rest  in  a  darkened  room  should  be  insisted  upon  and  an  ice 
helmet  applied.  The  bowels  should  be  kept  open  by  means  of  calomel. 
For  the  pain  the  coal  tar  analgesics,  acetanilide  gr.  v  (0.33),  acetphenetidine 
gr.  X  (0.66)  or  antipyrine  salicylate  (salipyrine)  gr.  x  (0.66)  may  be  given,  but 
in  severe  types  opium  may  be  necessary.  The  use  of  iodoform  internally 
and  externally  has  been  recommended;  6  to  10  grains  (0.4-0.66)  per  day 
may  be  given  or  an  ointment  of  20  percent,  strength  may  be  rubbed  into  the 
shaven  scalp;  potassium  iodide  in  doses  of  10  grains  (0.66)  three  times  a  day 
should  be  given  and  hot  applications — poultices  or  wet  compresses — to  the 
upper  spine,  and  leeches  to  the  temples  and  neck  are  useful.  The  inunction 
of  mercurial  ointment  to  the  limit  of  tolerance  in  non-tuberculous  cases  has 
its  advocates. 

The  delirium  and  other  symptoms  of  nervous  hypersesthesia  may  be  con- 
trolled by  the  bromides  and  hydrated  chloral,  and  good  results  have  followed 
the  relief  of  the  intra-cranial  pressure  by  means  of  lumbar  puncture;  rarely  a 
single  puncture  with  the  withdrawal  of  from  8  to  10  drachms  (30.0-37.50) 
of  the  fluid  will  result  in  recovery.  If  necessary  the  procedure  should  be 
repeated  at  daily  or  at  longer  intervals;  the  amount  withdrawn  at  a  single 
puncture  should  not  be  larger  than  that  above  specified. 

The  diet  should  be  of  milk,  other  like  fluids  and  broths. 

TUBERCULOUS  MENINGITIS. 

Synonym.     Acute  Hydrocephalus. 

Definition.  An  acute  inflammation  of  the  meninges  due  to  infection  by 
the  bacillus  tuberculosis. 

.Etiology.  This  disease  occurs  chiefly  in  children  from  two  to  ten  years 
old;  it  is  sometimes  seen  in  young  infants  but  rarely  in  adults.  Its  predis- 
posing causes  are  the  tuberculous  diathesis,  poor  hygienic  conditions  of  life 
and  the  presence  of  tuberculous  processes  in  other  parts  of  the  body.  It 
may  follow  an  attack  of  any  infectious  disease  especially  measles,  and  milk 
from  tuberculous  cows  may  be  an  exciting  cause. 

Pathology.  In  cases  of  very  acute  course  the  brain  is  the  seat  of  marked 
congestion  and  there  are  miliary  tubercles  scattered  over  the  pia  mater  of 
both  the  base  and  the  convexity.  In  other  cases  the  tubercles  are  also  found 
at  the  base  and  the  convexity,  in  the  ventricles,  the  choroid  plexus  and  often 
in  the  spinal  meninges;  they  are  most  abundant  in  the  neighborhood  of  the 
smaller   blood-vessels,  and  larger  tuberculous  deposits  in  which  bacilli  are 


730  DISEASES    OF    THE    NERVOUS    SYSTEM. 

found,  may  occur  as  a  result  of  the  coalescence  of  a  number  of  tubercles. 
There  may  be  areas  of  softening  due  to  the  obliteration  of  the  vessels  by  the 
products  of  the  inflammation.  There  may  be  deposits  of  fibrin,  the  arachnoid 
fluid  is  usually  increased  and  this  may  also  be  true  of  that  in  the  ventricles, 
which  at  times  may  become  so  abundant  as  to  compress  the  cerebral  substance. 

Symptoms.  Those  of  the  prodromal  period  are  headache,  irritability, 
dizziness,  prostration,  anorexia,  projectile  vomiting  without  nausea,  and 
constipation;  rarely  do  paralyses  of  the  facial  muscles  appear  in  the  prodromal 
stage.  These  symptoms  may  exist  for  several  weeks  before  the  appearance 
of  the  true  stage  of  irritation;  this  is  characterized  by  an  accentuation  of  the 
symptoms  already  present,  the  taclie  cerebrate,  inequalities  of  the  pupils, 
photophobia,  convulsions,  delirium,  paralyses,  etc.,  as  already  described  in  the 
section  on  leptomeningitis.  Succeeding  this  appears  the  comatose  stage,  with 
the  accompanying  evidences  of  cerebral  compression. 

The  diagnosis.  Lumbar  punctiu-e  is  a  great  aid  in  diagnosis;  tuberculous 
exudates  usually  do  not  contain  an  excess  of  polymorphonuclear  leucocytes, 
sugar  is  likely  to  be  present,  while  in  other  forms  of  meningitis  its  absence  is 
the  rule,  and  the  albumin  content  of  the  fluid  is  less  reduced  in  the  tuberculous 
exudate  than  in  those  of  other  origin.  The  presence  of  the  tubercle  bacillus 
assures  the  diagnosis,  but  its  absence  does  not  rule  out  tuberculous  infection 
as  a  causative  factor.     Indicanuria  may  occur  (Hochsinger's  sign). 

The  prognosis  is  distinctly  bad,  death  usually  supervening  in  three  or  four 
weeks. 

Treatment  consists  in  the  employment  of  the  measures  suggested  under 
the  treatment  of  leptomeningitis  (p.  729). 

CHRONIC  HYDROCEPHALUS. 

Definition.  A  condition  characterized  by  gradual  enlargement  of  the 
head  due  to  the  accumulation  of  serous  fluid  in  the  ventricles  of  the  brain. 

.Etiology.  The  disease  occurs  in  a  large  majority  of  instances  in  early 
infancy,  often  being  congenital.  Predisposing  causes  are  poor  bodily  condi- 
tion, unhealthful  surroundings,  rhachitis  and  parental  alcoholism,  plumbism 
or  syphilis. 

Pathology.  The  serous  exudation  which  characterizes  this  disease  is  the 
result  of  congenital  or  inflammatory  obstruction  of  the  aqueduct  of  Sylvius  or 
of  the  foramen  of  Magendie  and  the  lateral  foramina.  As  a  consequence  of 
this  the  ventricular  fluid  is  retained  and,  continually  increasing,  causes  disten- 
tion and  pressure.  The  lateral  ventricles,  one  or  both,  are  the  most  frequent 
seats  of  this  distention  which  may  be  so  extreme  as  to  compress  the  cerebral 
cortex  to  the  thinness  of  half  an  inch  or  less.  More  rarely  does  the  disten- 
tion affect  only  the  fourth  ventricle. 


CEREBRAL    HEMORRHAGE.  73 1 

Symptoms.  In  congenital  instances  the  size  of  the  head  may  be  so  great  as 
to  necessitate  instrumental  delivery  or  even  craniotomy.  When  the  disease 
appears  after  birth  the  size  of  the  head  gradually  increases,  the  frontal  and 
occipital  regions  bulge,  the  fontanelles  and  sutures  bulge  and  spread  and  the 
presence  of  fluid  may  be  detected  by  palpation.  The  facies  does  not  increase 
in  size  correspondingly;  as  the  condition  becomes  more  marked,  mental  symp- 
toms appear;  the  child  is  easily  irritated;  both  mental  and  physical  growth 
are  delayed.  In  the  severe  instances  the  child  may  not  learn  to  walk  or  talk, 
the  intracranial  pressure  results  in  optic  atrophy  or  strabismus,  there  are 
vomiting  and  convulsions;  coma  may  supervene  and  death  from  asthenia  or 
intercurrent  disease  results,  although  this  event  may  not  take  place  for 
several  years.  In  instances  of  less  severity  the  progress  of  the  condition 
ceases,  the  cranial  bones  unite  and  become  hard  and  firm  and  the  mental  and 
physical  processes  become  normal. 

Chronic  hydrocephalus  occurring  later  in  life  is  evidenced  by  vague  symp- 
toms of  compression  and  is  difficult  of  recognition. 

Treatment  is  unsatisfactory;  the  symptoms  should  be  met  .as  they  arise  and, 
upon  the  possibility  of  syphilis  being  the  causative  factor,  inunctions  of  mer- 
cury and  the  internal  administration  of  potassium  iodide  should  be  prescribed. 
Surgical  and  other  measures  are  of  little  value.  Lumbar  puncture  will  relieve 
the  pressure  temporarily  but  the  fluid  returns. 

APOPLEXY. 
CEREBRAL  HEMORRHAGE. 

Definition.  Apoplexy  is  the  term  applied  to  the  train  of  symptoms  which 
follows  the  rupture  of  an  intracranial  blood-vessel  or  that  which  results  upon 
embolism  or  thrombosis  of  these  structures. 

.Etiology.  Cerebral  hsemorrhage  is  seen  rather  more  frequently  in  males 
than  in  females  and  is  most  common  in  individuals  beyond  middle  life.  This 
is  the  case  merely  because  arterial  degeneration  affects  men  more  often  and 
occurs  chiefly  in  those  over  40.  The  kidneys  are  diseased  in  a  large  number 
of  instances  and  as  predisposing  causes  syphilis,  alcoholism  and  gout  play  an 
important  role.  An  artery  weakened  by  injury  or  chronic  inflammation  may 
at  any  time  rupture  as  a  result  of  increased  blood  pressm-e,  which  condition 
may  be  due  to  emotional  or  sexual  excitement,  straining  at  stool,  an  undue 
physical  effort,  alcoholic  excess,  over-eating,  etc. 

Pathology.  The  morbid  anatomy  of  cerebral  haemorrhage  before  actual 
rupture  takes  place  is  that  of  arteriosclerosis  (p.  606);  there  are  roughening 
of  the  intima,  fatty  degeneration  of  the  muscular  coat  and  fibrous  changes 
in  the  externa.     Miliary  aneiu^'sms  are  found  upon  the  smaller  arteries  as  a 


732  DISEASES    OF    THE    NERVOUS    SYSTEM. 

result  of  the  degeneration  of  the  artery  wall;  atheromatous  changes  affect  the 
larger  arteries.  The  vessel  which  most  frequently  ruptures  is  the  lenticular 
striate  branch  of  the  middle  cerebral  artery,  consequently  cerebral  haemorrhage 
is  most  usually  seen  in  or  near  the  caudate  and  lenticular  nuclei.  The  branches 
of  the  anterior  cerebral  artery  rupture  less  often  and  those  of  the  posterior 
cerebral,  rarely.  The  reason  for  the  election  of  the  middle  cerebral  is  that 
this  vessel  seems  more  prone  to  degenerative  changes  than  the  others  and  that 
it  is  in  more  direct  communication  with  the  heart;  consequently  it  receives  the 
blood  under  greater  pressure  than  do  the  other  vessels  mentioned.  Large 
haemorrhages  and  those  under  high  pressure  may  burst  through  into  the  ventri- 
cles and  reaching  the  fourth  ventricle,  result  in  death  from  pressure  upon  the 
centers  there  situated.  The  fourth  ventricle  is  especially  likely  to  be  affected 
in  cerebellar  haemorrhage.  After  extravasation  the  blood  furst  coagulates; 
the  clot  then  softens  and  absorption  begins;  in  about  a  week  a  wall  of  fibrin 
is  formed  about  the  clot  which  becomes  encysted  within  its  fibrinous  wall, 
contraction  of  the  cyst  wall  finally  taking  place. 

Symptoms.  Prodromal  symptoms  such  as  a  feeling  of  fulness  in  the  head, 
dizziness,  numbness  and  tingling  of  an  extremity,  ringing  in  the  ears,  irregular 
heart  action,  etc.,  may  occur;  the  usual  onset  of  a  "stroke"  is  evidenced  by 
sudden  loss  of  consciousness;  if  standing,  the  patient  falls;  more  rarely  is  an 
attack  ushered  in  by  convulsions  and  a  seizure  may  take  place  without  coma. 
After  the  typical  onset  the  patient  is  seen  in  an  absolutely  comatose  state, 
his  face  is  flushed,  cyanotic  or  pale,  the  pulse  is  of  high  tension  and  usually 
slow,  the  respiration  is  slow  and  stertorous;  it  may  be  irregular  and  expiration 
is  accompanied  by  an  inflation  of  one  cheek.  The  pupils  may  be  contracted, 
dilated  or  unequal  but  they  usually  do  not  respond  to  light.  At  the  time  of 
the  attack  the  temperature  falls  to  a  subnormal  level — later  it  rises. 

Examination  usually  reveals  a  paralysis,  most  frequently  a  hemiplegia  with 
lack  of  sensation,  the  arm  and  leg  if  raised  fall  limply,  rarely  are  they  rigid; 
the  reflexes  are  lost  or  very  greatly  diminished;  the  tongue  protrudes  toward 
the  paralyzed  side.  After  the  return  of  consciousness,  when  the  right  side  is 
affected,  there  is  inability  to  speak  (aphasia — see  p.  737).  The  bladder  and 
rectum  may  be  incontinent  or  there  may  be  retention  of  urine;  examination 
of  the  latter  often  shows  the  presence  of  albumin. 

In  the  rapidly  fatal  instances  there  may  be  no  retiu-n  to  consciousness,  the 
pulse  becomes  more  rapid,  the  respiration  may  change  to  the  Cheyne-Stokes 
type,  the  temperature  rises  to  io3°-io4°  F.  (39.5°-4o.°C.)  and  death  supervenes; 
just  before  death  the  temperature  may  fall.  In  fatal  instances  of  slower  course 
the  coma  partially  disappears,  giving  way  to  stupor  or  delirium,  the  tempera- 
ture remains  only  slightly  elevated,  being  higher  upon  the  affected  side;  hypo- 
static pneumonia  may  develop,  to  be  followed  by  death  after  a  few  weeks. 

The  patients  who  go  on  to  the  chronic  stage  gradually  regain  sensibility, 


CEREBRAL    HEMORRHAGE.  733 

the  aphasia  partially  or  wholly  disappears  and  the  paralysis  slowly  improves 
to  the  extent  that  the  affected  limbs  can  be  slightly  moved  and  sensation  is 
partly  regained;  the  mind  may  be  permanently  impaired. 

The  patient  has  now  become  a  hemiplegic;  the  facial  muscles  are  least 
disturbed,  those  of  the  arm  most,  those  of  the  voice  and  of  the  chest  are  very 
little  affected;  the  knee  and  ankle  jerks  are  exaggerated.  Contractures  with 
resulting  deformity  are  developed;  these  involve  the  extensors  of  the  foot 
more  than  the  flexors,  while  the  opposite  is  the  case  in  those  of  the  upper  limb. 
There  is  no  atrophy  of  the  muscles  and  while  their  electrical  reaction  is  dis- 
turbed, the  so-called  reaction  of  degeneration  does  not  result.  Various  motor 
disorders  may  develop;  tremors,  choreic,  athetoid,  and  ataxic  movements,  etc. 
Complete  anaesthesia  is  seldom  seen  but  paraesthesiae  are  frequently  observed. 
Trophic  and  vaso-motor  disorders,  such  as  swelling  of  the  extremities,  sweating 
and  skin  eruptions,  may  occur.  The  nutrition  usually  continues  good  but 
in  patients  who  are  confined  to  the  bed,  bed-sores  are  very  prone  to  develop. 
Progressive  emaciation  is  rare. 

The  diagnosis  of  cerebral  haemorrhage  is  often  most  difficult. .  A  consider- 
able number  of  conditions  must  be  differentiated  from  it;  among  these  are 
the  following: 

Alcoholic  coma.  In  this  state  the  insensibility  is  less  complete,  the  patient 
may  be  aroused  by  the  inhalation  of  ammonia  or  by  pressure  upon  the  supra- 
orbital nerves;  the  pulse  is  rapid,  the  temperature  is  not  subnormal,  one  cheek 
is  not  inflated  and  drawn  in  with  respiration,  there  are  no  signs  of  paralysis, 
the  pupils  are  equal  and  reactive  and  the  odor  of  the  breath  is  characteristic. 

Opium  poisoning.  The  onset  of  the  coma  is  gradual,  the  pupils  are  con- 
tracted and  equal,  the  temperature  is  normal,  the  respiration  slow,  there  is 
no  paralysis,  the  patient  may  be  partially  aroused  and  the  examination  of 
the  stomach  contents  is  characteristic  unless  the  drug  has  been  taken  hypo- 
dermatically;  in  this  case  the  needle  puncture  may  be  found.  There  is  no 
paralysis. 

UrcBmic  coma.  Here  we  may  have  a  history  of  antecedent  convulsion, 
there  may  be  oedema  and  the  waxy  skin  of  the  large  white  kidney,  the  pupils 
are  equal  and  the  urine  contains  albumin  and  casts;  the  pulse  is  usually  weak 
and  irregular  and  the  respiration  rapid.  The  evidences  of  pregnancy  are  a 
strong  point  in  favor  of  iiraemia. 

Epilepsy.  The  coma  is  preceded  by  the  characteristic  cry,  there  is  a  history 
of  previous  attacks,  there  is  frothing  at  the  mouth;  the  tongue  may  be  bitten, 
the  pupils  are  equal  and  dilated  and  there  is  no  paralysis. 

Cerebral  embolism.  This  is  more  likely  to  occur  in  young  individuals, 
there  often  is  evidence  of  vahoilar  heart  lesion;  the  coma  is  slighter  in  character 
and  shorter  in  duration,  the  paralysis  usually  appears  first  and  is  followed 
by  the  convulsion  and  the  loss  of  consciousness.     Seizures  after  child  birth 


734  DISEASES    OF    THE    NERVOUS    SYSTEM. 

are  more  likely  to  be  due  to  embolism.    There  is  little  disturbance  of  tempera- 
ture, and  the  tense  pulse  and  stertorous  breathing  are  absent. 

Cerebral  thrombosis.  Here  we  may  have  a  history  of  light  attacks  from 
which  recovery  is  quick;  the  patient  is  usually  aged  and  presents  the  signs  of 
atheroma;  convulsions,  stertor  and  abnormal  temperature  are  wanting.  The 
pupils  are  usually  undisturbed. 

Treatment.  The  patient  should  be  immediately  placed  in  a  horizontal 
position,  but  with  the  head  elevated.  An  ice  bag  should  be  applied  to  the 
head  and  hot  water  bags  to  the  feet.  The  lower  limbs  may  be  wrapped  in 
towels  saturated  with  hot  mustard  water — a  tablespoonful  (15.0)  of  mustard 
to  2  quarts  (litres)  of  water.  If  the  pulse  is  of  markedly  high  tension  about 
8  ounces  (250.0)  of  blood  should  be  drawn  from  one  of  the  median  basilic 
veins.  The  bowels  should  be  moved  by  an  enema  of  warm  water  and  a  purge 
administered;  those  preferable  are  croton  oil,  i  or  2  drops  (0.065-0.13) 
mixed  with  a  little  olive  oil  and  placed  at  the  back  of  the  tongue  or  elaterium, 
gr.  ^  to  gr.  ^  (0.008-0.016)  on  account  of  their  ease  of  administration  and 
rapid  action.  In  moderate  degrees  of  vascular  tension,  even  after  venesection, 
aconite  or  veratrum  viride — the  tinctures  in  doses  of  i  drop  (0.065)  every 
30  minutes — should  be  given  until  the  tension  becomes  lower.  Compression 
or  ligation  of  the  carotid  artery  has  been  advocated  with  a  view  to  lessening 
the  haemorrhage.  The  bladder  should  be  watched  and  the  urine  drawn  if 
necessary. 

Following  the  treatment  of  the  seizure,  measures  should  be  taken  to  pre- 
serve the  nutrition  of  the  patient;  rectal  feeding  may  become  necessary.  Bed- 
sores should  be  prevented  by  attention  to  the  cleanliness  of  the  bed,  and  of  the 
patient's  skin.  The  buttocks  and  heels  should  be  rubbed  with  alcohol  and 
powdered  daily  and  the  sheets  should  be  kept  as  smooth  as  possible.  The 
patient  should  be  frequently  turned  upon  his  sides  both  to  guard  against  bed- 
sores and  against  hypostatic  pneumonia,  additional  points  in  the  prophyla.xis 
of  which  are  frequent  thorough  cleansing  of  the  mouth  with  an  antiseptic 
solution  and  care  lest  particles  of  food  be  breathed  into  the  lungs. 

The  treatment  of  the  chronic  stage  consists  in  the  internal  administration 
of  sodium  or  potassium  iodide,  together  with  general  tonics,  such  as  iron, 
strychnine  and  quinine,  and  attention  to  the  action  of  the  bowels  and  kidneys. 
Arterial  tension  when  it  occurs  should  be  relieved  by  means  of  glyceryl  nitrate 
gr.  xio'~To  (0.0006-0.0012)  every  four  to  six  hours.  Several  weeks  after  the 
attack  the  use  of  thefaradic  current  upon  the  affected  muscles  should  be  begun 
and  continued  at  daily  intervals,  later  static  electricity  is  also  beneficial. 
Massage  and  exercises  adapted  to  the  patient's  abilities  are  important  and 
warm  baths  are  useful.  The  physical  means  above  mentioned  are  effectual 
both  in  the  prevention  of  contractures  and  in  the  maintenance  of  muscular 
nutrition.     The    administration  of  small  doses  of  strychnine — gr.  y^-^  to 


EMBOLISM    AND    THROMBOSIS    OF    THE    CEREBRAL    ARTERIES.     735 

y-J-0  (0.0005-0.0006),  of  physostigmine  salicylate  gr.  y^oto  -g^o  (0.0006-0.001) 
and  of  the  bromides  is  said  to  be  attended  with  good  results  when  con- 
tractures are  present. 

The  mode  of  life  should  be  regular  and  quiet,  a  temperate  climate  is  pref- 
erable and  the  diet  should  be  simple. 

In  cases  of  fracture  and  where  there  is  reason  to  suspect  a  cortical  or  men- 
ingeal haemorrhage,  trephining  of  the  skull  and  relief  of  the  pressure  is  justi- 
fiable and  the  results  obtained  are  often  excellent. 

EMBOLISM  AND  THROMBOSIS  OF  THE  CEREBRAL  ARTERIES. 

Synonym.     Acute  Cerebral  Softening. 

Definition.  Embolism  is  the  term  applied  to  the  plugging  of  a  blood-vessel 
by  a  clot  or  other  foreign  body  brought  to  its  place  of  lodgment  by  the 
blood  current. 

By  thrombosis  is  meant  the  stoppage  of  a  blood-vessel  by  a  clot  developed 
in  situ. 

.Etiology.  Embolism  is  seen  somewhat  more  often  in  females,  thrombosis 
in  males;  embolism  may  occur  in  children  or  young  persons  while  thrombosis 
is  rare  before  middle  life.  Predisposing  causes  are  acute  or  chronic  valvular 
heart  lesions,  aneurysm,  endarteritis,  blood  diseases,  acute  infectious  diseases 
and  pregnancy.  The  embolus  is  carried  by  the  most  direct  route  to  the  cere- 
bral circulation,  i.e.,  through  one  of  the  carotids,  more  particularly  the  left, 
to  the  internal  carotid  and  thence  to  the  left  middle  cerebral  artery,  or  less 
frequently  to  the  posterior  cerebral  branch  of  the  vertebral  artery. 

Thrombosis  is  predisposed  to  by  arteritis  due  to  any  cause,  weak  or  fatty 
heart  and  blood  dyscrasiae;  carotid  ligation  may  be  followed  by  cerebral  throm- 
bosis. The  vessel  most  frequently  involved  is  the  middle  cerebral;  the  basilar 
artery  is  a*not  uncommon  situation  for  thrombosis;  less  often  is  there  obstruc- 
tion in  the  vertebral  and  posterior  cerebral  arteries  and  in  one  of  the  various 
branches  of  the  circle  of  Willis. 

Pathology.  The  stoppage  of  the  blood  current  by  the  embolus  or  thrombus 
deprives  a  certain  area  of  the  brain  of  its  blood  supply.  Degeneration  and  soft- 
ening of  this  area  begin  usually  in  about  twenty-four  hours.  If  in  the  gray 
matter,  the  tissue  supplied  by  the  occluded  vessel  becomes  red  (red  softening) 
and  later  yellow  (yellow  softening).  The  area  of  softening  is  finally  absorbed, 
a  scar  or  a  cyst  remaining,  unless  the  embolus  is  infective,  when  local  inflam- 
mation or  abscess  may  result.  The  arteries  in  cases  of  thrombosis  usually 
give  evidence  of  endarteritis  affecting  chiefly  the  cerebral  arteries,  anterior, 
middle  and  posterior,  as  well  as  the  vertebral  and  basilar  arteries.  Post- 
thrombotic  softening  is  analogous  to  that  following  embolisn  and  the  two 
conditions  may  co-exist  owing  to  the  detachment  of  a  bit  of  the  clot  and  its 


736  DISEASES   OF   THE    NERVOUS    SYSTEM. 

subsequent  lodgment;  rupture  of  one  of  the  cerebral  vessels  may  follow 
either  thrombosis  or  embolism. 

Symptoms.  Both  embolism  and  thrombosis  may  take  place  without 
causing  recognizable  symptoms  if  the  condition  occurs  in  a  vessel  possessing 
free  anastomoses,  since  a  collateral  circulation  is  immediately  set  up.  When, 
however,  there  is  a  stoppage  in  a  terminal  artery  the  picture  is  a  markedly 
different  one.  Prodromal  symptoms  seldom  occur  in  embolism.  The  onset 
may  be  marked  by  slight  muscular  twitchings  with  subsequent  coma  and 
hemiplegia,  the  two  latter  manifestations  alone  may  appear,  or  the  coma 
may  be  entirely  absent.  The  suffused  facies,  stertor  and  arterial  tension 
characteristic  of  haemorrhage  are  absent.     Vomiting  is  a  rare  symptom. 

Prodromata  are  the  rule  in  thrombosis;  headache,  dizziness,  disturbances 
of  the  cranial  nerves,  numbness  and  tingling  of  the  extremities,  and  temporary 
paralyses  or  aphasia  may  be  observed.  Here  the  coma  and  hemiplegia  are 
of  gradual  development  in  most  instances  but  these  symptoms  may  appear  sud- 
denly; the  coma  may  be  wholly  lacking.  The  temperature  is  not  markedly 
disturbed  but  may  be  subnormal  at  first;  it  may  rise  later.  When  a  terminal 
vessel  is  not  involved  the  paralysis  soon  begins  to  improve,  owing  to  the  estab- 
lishment of  a  collateral  circulation. 

In  marked  instances  with  considerable  areas  of  softening  the  patient  may  die 
within  a  day  or  two;  death  in  less  severe  cases  may  not  take  place  for  a  number 
of  weeks  or  the  patient  may  pass  on  to  the  chronic  stage,  a  state  closely  allied 
in  symptoms  to  that  following  cerebral  haemorrhage. 

The  differential  diagnosis  has  been  discussed  upon  p.  733. 

The  prognosis  in  embolism  is  good,  as  a  rule,  as  regards  recovery  unless  the 
obstruction  has  lodged  in  a  very  large  artery,  when  the  condition  ends  in  death. 
Recurrences  in  both  embolism  and  thrombosis  may  occur,  more  commonly 
in  the  latter  and  each  attack  is  more  serious  than  the  preceding.  The  prog- 
nosis of  the  chronic  stage  is  poor,  as  regards  recovery,  in  both  conditions. 

Treatment.  The  patient  should  be  put  to  bed  with  his  head  elevated. 
Venesection  is  contraindicated  but  the  heart  action  should  be  stimulated  if 
necessary  by  means  of  glyceryl  nitrate,  digitalis  or  strophanthus;  the  two 
latter  are  particularly  indicated  in  embolism,  the  first  in  thrombosis.  Potas- 
sium iodide  is  also  useful  in  relaxing  arterial  tension  and  is  likely  to  be  more 
permanent  in  its  effect  than  glyceryl  nitrate.  The  dose  of  the  former  is  10 
grains  (0.66)  or  more,  that  of  the  latter,  gr.  y^-q  togr.  -J^  (0.0006-0.0012)  three 
times  a  day.  The  action  of  the  bowels  and  kidneys  should  be  maintained 
in  as  nearly  a  normal  state  as  possible.  When  there  is  possibility  of  a  syphilitic 
element  in  the  aetiology  of  the  condition  treatment  by  means  of  mercury  and 
the  iodides  should  be  at  once  instituted. 

The  management  of  the  chronic  stage  is  identical  with  that  of  the  corre- 
sponding state  in  cerebral  haemorrhage.     (See  p.  734.) 


THROMBOSIS    OF    THE    VENOUS    SINUSES    OF    THE    BRAIN.  737 

THROMBOSIS  OF  THE  VENOUS  SINUSES  OF  THE  BRAIN. 

Sinus  thrombosis  occurs  in  both  a  primary  and  a  secondary  form.  The 
former  is  seen  in  states  of  poor  bodily  nutrition  and  weakened  conditions. 
It  may  take  place  in  infants  as  a  result  of  chronic  wasting  diseases,  especially 
in  diarrhoeal  conditions,  it  may  result  from  various  blood  dyscrasiae,  and 
may  complicate  such  constitutional  diseases  as  tuberculosis  and  cancer. 

Secondary  thrombosis  is  observed  as  a  complication  of  various  inflammatory 
conditions  in  the  neighborhood  of  a  sinus,  such  as  internal  ear  and  mastoid 
disease,  fractures  of  the  skull  and  any  suppiurative  process. 

Symptoms.  Primary  thrombosis  may  be  attended  by  few  or  no  symp- 
toms; those  most  frequently  seen  are  headache,  nausea,  vomiting  and  coma 
of  very  gradual  development.  Paralyses  and  pupillary  dilatation  are  more 
rare. 

Secondary  sinus  thrombosis  is  preceded  by  otitis,  cranial  fracture,  etc.,  and 
their  attendant  symptoms;  its  nature  is  infective  and  it  is  usually  ushered  in 
by  a  chill  followed  by  a  rise  in  temperature.  There  is  severe  occipital  head- 
ache, the  patient  may  be  stuporous  or  delirious,  and  convulsions  may  take 
place  as  well  as  the  other  symptoms  of  meningeal  inflammation.  The  sinuses 
involved  are  usually  those  in  the  neighborhood  of  the  ear. 

The  prognosis  is  serious,  death  in  the  secondary  form  usually  occurring 
after  two  or  three  weeks  and  often  being  due  to  septic  pneumonia,  which  has 
its  origin  in  emboli  brought  from  the  affected  sinus  to  the  lung  by  the  venous 
circulation. 

Treatment  consists,  in  the  primary  form,  of  such  measures  as  are  called 
for  by  the  causative  factor;  in  the  secondary  variety  surgical  procedures  must 
be  employed  with  a  view  to  the  removal  of  the  septic  focus.  For  a  descrip- 
tion of  these  the  reader  is  referred  to  works  upon  surgery  and  operative 
otology.  After  treatment  calculated  to  improve  the  patient's  general  condition 
— quinine,  iron,  strychnine,  etc. — should  be  employed. 

APHASIA. 

This  is  the  term  applied  to  defects  or  loss  of  the  power  of  speech;  aphasia 
occurs  in  various  forms  differing  with  the  part  of  the  speech  mechanism  affected. 
In  considering  aphasia  we  include  the  faculty  of  transmitting  to  others  our 
thoughts  by  spoken  or  written  words  and  by  gestures,  as  well  as  the  faculties 
by  which  we  see,  hear  and  realize  the  significance  of  objects.  Aphasia  is 
regarded  as  sensory  or  motor  according  as  it  is  the  result  of  inability  to  remem- 
ber words  or  to  speak  them,  consequently  it  may  be  caused  by  disorder  of 
either  the  receptive  or  the  emissive  center. 

Sensory  aphasia.  Under  this  term  we  include  word  blindness,  word 
deafness  and  amnesic  aphasia.  Word  blindness  is  the  term  applied  to  failure 
47 


738  DISEASES    OF   THE    NERVOUS    SYSTEM. 

to  remember  the  appearance  of  a  word.  The  patient  afflicted  with  this  con- 
dition does  not  recognize  the  written  or  printed  word  while  he  may  be  able 
to  pronounce  it  when  repeated  by  another,  to  copy  it  or  to  write  it  from  dictation; 
the  memory  for  figures,  however,  may  remain  normal.  Motor  aphasia  may 
co-exist  with  this  affection  and  the  portion  of  the  brain  at  fault  is  believed  to 
be  some  part  of  the  left  angular  or  supramarginal  convolution. 

Word  deafness  is  a  condition  in  which,  while  the  sense  of  hearing  remains 
undisturbed,  the  meaning  of  words  is  lost;  musical  tones  also  may  be  unrec- 
ognized. This  is  a  rare  affection  and  is  usually  accompanied  by  other  varie- 
ties of  sensory  aphasia  although  it  may  occur  independently.  The  part  of 
the  brain  affected  is  the  posterior  part  of  the  first  and  second  left  temporal 
convolutions  in  right-handed  individuals  and  a  corresponding  area  on  the 
right  hemisphere  in  the  left-handed. 

Amnesic  aphasia  is  a  state  in  which  the  patient  is  unable  to  remember  a 
word;  if  it  is  supplied  to  him  he  recognizes  and  repeats  it.  He  may  be  thus 
affected  as  regards  all  words  or  only  a  few,  perhaps  but  a  single  one,  his  name 
for  instance. 

Agraphia  is  an  analogous  condition  in  which  the  patient  is  unable  to  write 
a  word  because  he  cannot  remember  it;  he  can,  however,  usually  write  at 
dictation. 

These  last  two  affections  are  probably  caused  by  a  disturbance  of  the  asso- 
ciation tracts. 

Motor  or  ataxic  aphasia.  In  this  disorder  the  patient  is  quite  aware  of 
the  word  he  desires  to  say  but  is  wholly  unable  to  say  it,  neither  can  he, 
if  it  is  supplied  by  a  second  person,  repeat  it.  If  he  is  a  linguist  he  may  lose 
the  power  of  all  tongues  save  one;  he  may  be  able  to  read  to  himself  and  under- 
stand the  speech  of  others  while  entirely  unable  to  speak  himself,  or  while 
able  to  articulate  a  few  words,  he  may  mispronounce  these  or  leave  out  syllables 
or  letters.  In  this  condition  the  lesion  is  in  the  third  left  frontal  convolution 
and  consequently  is  a  frequent  accompaniment  of  right  hemiplegia.  Alexia, 
or  lack  of  the  power  to  read  aloud,  is  usually  an  accompaniment  of  this  form 
of  aphasia. 

Atypical  and  mixed  forms  of  aphasia  are  not  unusual,  a  patient  sometimes 
using  the  wrong  word  to  express  an  idea  because  of  a  confusion  of  thought. 

GENERAL  PARALYSIS. 

Synonyms.  General  Paresis;  Dementia  Paralytica;  Chronic  Diffuse  Men- 
ingo-encephalitis;  Paretic  Dementia. 

Definition.  A  chronic  progressive  inflammatory  disease  of  the  central 
nervous  system,  especially  of  the  cerebrum  and  its  pia  mater,  resulting  in 
loss  of  mental  and  physical  power  and  ending  in  insanity  and  paralysis. 


GENERAL    PARALYSIS. 


739 


etiology.  This  disease  is  one  of  middle  life  and  is  more  common  in 
males,  although  it  has  been  observed  in  congenitally  syphilitic  children. 
The  chief  causative  factor  is  specific  disease,  syphilis  being  responsible  for 
at  least  75  percent. — perhaps  a  much  greater  proportion — of  all  cases.  It  is 
a  disease  of  the  higher  classes  of  society  and  is  predisposed  to  by  excesses  of 
every  variety,  mental  over-w^ork  and  worry. 

Pathology.  The  gross  changes  seen  in  the  brain  consist  of  atrophy,  partic- 
ularly involving  the  frontal  lobes;  their  color  is  lighter  and  their  texture  more 
firm  than  normal,  the  convolutions  are  slirunken,  the  fissures  widened,  cysts 
may  be  present  in  both  white  and  gray  matter;  there  is  also  thickening  of  the 
dura  mater  and  of  the  pia.  The  latter  is  oedematous  and  may  be  adherent 
to  the  brain.  Upon  microscopical  examination  the  walls  of  the  blood  and 
lymph  vessels  are  seen  to  be  thickened,  the  hypertrophy  of  the  former  resulting 
in  fusiform  dilatations,  and  there  is  exudation  of  serum  into  the  lymph  spaces, 
resulting  finally  in  an  oedema  of  the  cerebrum.  The  nerve  tissue  itself  is 
destroyed  and  replaced  by  neuroglia.  The  cerebral  neurons  are  the  seat 
of  degeneration  and  finally  atrophy.  These  changes  affect  the  cerebral 
ganglia  as  well  as  the  white  and  gray  matter. 

Sclerotic  changes  of  the  cord,  analogous  to  those  of  tabes,  particularly  in 
the  posterior  and  lateral  columns,  are  also  present. 

Symptoms.  Those  of  the  first  stage  or  that  of  onset,  may  last  for  months 
or  even  a  year  or  more  and  are  both  mental  and  motor  in  character.  The 
patient  is  subject  to  delusions  of  grandeur  accompanied  by  unusual  actions, 
loss  of  memory  and  lack  of  judgment.  He  may  indulge  in  extravagant  finan- 
cial operations  and  make  impossible  promises  or  contracts;  he  may  be 
irritable  and  easily  excitable  or  morose,  and  despondent;  he  may  suffer  from 
insomnia.  The  motor  disorders  chiefly  affect  speech  and  handwriting. 
The  former  becomes  hesitating  and  indistinct,  syllables  and  words  may  be 
slurred  and  difficulty  is  experienced  over  complicated  phrases  such  as  "  third 
artillery  brigade"  and  "around  the  rough  and  rugged  rocks  the  ragged  rascal 
ran."  The  handwriting  is  shaky,  syllables  are  omitted,  words  mispelled 
and  wrong  letters  inserted 

The  pupils  may  be  unequal,  the  patellar  reflex  may  be  absent  in  cases  with 
sclerosis  of  the  posterior  columns  of  the  cord  or  it  may  be  exaggerated  in 
spastic  cases. 

In  the  second  stage  the  above  symptoms  are  more  intense,  the  mental  state 
may  be  violent  or  maniacal  and  the  delusions  more  extraordinary,  or,  on  the 
other  hand,  the  depression  may  become  more  marked,  even  to  pronounced 
melancholia,  and  the  physical  condition  becomes  much  deteriorated.  There 
is  progressive  increase  of  the  disturbance  of  speech  and  handwriting,  the 
former  may  become  entirely  incomprehensible  and  the  power  of  wTiting  entirely 
lost.     Epileptiform  and  apoplectiform  seizures  may  occur,  the  gait  is  disor- 


740  DISEASES    OF    THE    NERVOUS    SYSTEM. 

dered,  and  mono-  or  hemiplegia  may  develop.  Ataxia,  loss  of  sensation  and 
paralysis  of  bladder  and  rectum  are  not  infrequent.  Bulbar  symptoms 
follow  and  the  patient  becomes  helpless,  the  loss  of  mental  power  is  complete 
and  death  supervenes  from  exhaustion  or  from  concurrent  disease. 

The  course  of  general  paralysis  is  usually  from  three  to  six  years  but  a 
type  of  rapid  course  is  met  in  which  the  stages  are  shortened  to  a  few  months; 
here  the  loss  of  flesh  and  strength  takes  place  very  rapidly. 

The  prognosis.  While  encouraging  remissions  in  the  development  of 
the  symptoms  occur  at  times  the  disease  is  bound  to  progress  and  the  ultimate 
fatal  result  is  certain,  consequently  the  prognosis  as  to  recovery  is  wholly 
bad. 

Treatment.  Institution  treatment  where  a  properly  hygienic  mode  of  life 
can  be  carried  out,  with  plenty  of  fresh  air,  bathing  and  massage,  should  be 
insisted  upon.  While  the  action  of  anti-syphilitic  treatment  is  in  no  sense 
specific,  it  may  lessen  the  rapidity  of  the  progress  of  the  disease  and  in  view 
of  the  frequency  of  a  luetic  element  in  the  aetiology,  a  course  of  treatment  by 
inunctions  of  mercury  and  the  internal  administration  of  potassium  iodide 
in  increasing  doses  even  up  to  loo  or  more  grains  (6.66)  per  day,  should  be 
instituted. 

Otherwise  the  treatment  should  be  such  as  to  combat  the  symptoms  as 
they  arise;  the  excitability  may  be  relieved  by  the  bromides;  for  the  sleepless- 
ness the  milder  hypnotics  such  as  sulphonmethane — gr.  xx  (1.33) — sulphon- 
ethylmethane — gr.  x  (o.66)^or  veronal — gr.  x  to  xv  (0.66-1.0) — are  indi- 
cated. The  attacks  of  marked  delirium  may  necessitate  the  administration 
of  hyoscine  hydrobromide,  gr.  y^-g-  (0.0006)  hypodermatically.  The  bowels 
should  be  kept  open  by  laxatives  if  necessary  and  the  patient's  nutrition  main- 
tained by  means  of  a  nourishing  and  easily  digestible  diet. 

DISSEMINATED  SCLEROSIS. 

Synonyms.     Multiple  Sclerosis;  Insular  Sclerosis;  Sclerose  en  Plaques. 

Definition.  A  chronic  inflammation  of  the  central  nervous  system  charac- 
terized by  the  development  of  patches  of  sclerosis  in  various  parts  of  the 
brain  and  cord. 

.Etiology.  The  direct  causation  of  this  condition  is  unknown.  It  is 
seen  in  both  sexes  with  equal  frequency,  and,  while  it  may  occur  at  any  age, 
is  rare  in  childhood  and  most  common  between  the  ages  of  twenty  and  forty. 
It  is  said  to  follow  the  acute  infectious  diseases  and  also  to  result  from  ex- 
posure to  cold,  emotional  disturbances  and  syphilis. 

Pathology.  Throughout  the  brain  and  spinal  cord  are  irregularly  scattered 
patches  of  sclerosed  tissue.  These  are  grayish  in  color  and  firm  in  consis- 
tency; their  outline  is  irregular  and  distinct  and  their  diameter  may  be  yg-  of 


DISSEMINATED    SCLEROSIS.  741 

an  inch  or  more.  They  are  rarely  seen  in  the  cortex,  their  usual  sites  in  the 
brain  being  about  the  lateral  ventricles,  the  corpus  callosum,  the  pons  and 
the  cerebellum;  they  are  infrequent  in  the  pons  but  many  may  be  found 
in  the  cord,  particularly  in  the  white  matter.  The  type  of  the  sclerosis  is 
analogous  to  that  occurring  in  other  tissues;  the  neuroglia  is  increased  at  the 
expense  of  the  nerve  cells  and  fibres  and  the  walls  of  the  blood-vessels  are 
thickened.  When  the  process  is  advanced  the  nerve  cells  themselves  become 
degenerated  and  fatty  granular  cells  may  be  present.  In  the  nerve  fibres 
the  white  substance  is  first  involved,  later  the  axis  cylinder,  which  ultimately 
is  wholly  destroyed;  this  latter,  however,  is  a  late  change,  the  axis  cylinders 
remaining  intact  long  after  their  sheaths  have  succumbed  to  the  sclerotic 
process. 

Symptoms.  The  occurrence  of  this  disease  with  other  lesions,  together 
with  its  slow  development,  renders  its  recognition  difficult.  The  symptoms 
depend  upon  the  portions  of  the  nervous  system  involved  in  the  sclerotic  proc- 
ess. (An  important  early  symptom  is  an  ataxia  of  the  limbs,  resembling,  in  the 
legs,  the  symptoms  of  spastic  paraplegia  with  stiff  and  aw^kward  gait,  showing 
that  the  pyramidal  tracts  are  affected,  here  we  find  the  patellar  reflex  and  the 
ankle  clonus  increased.  The  so-called  intention-tremor  is  a  typical  symptom 
manifesting  itself  by  an  incoordination  of  the  hands,  a  marked  tremor  being 
observed  when  the  patient  lifts  a  glass  to  the  mouth  or  tries  to  pick  up  a  small 
object;  the  tremor  ceases  when  the  patient  desists  from  his  endeavor.  A 
like  tremor  affects  the  head  and  trunk.  The  Romberg  symptom  may  be 
present.  Nystagmus  and  various  ophthalmic  disturbances  are  common; 
these  are  due  to  sclerotic  patches  in  the  optic  nerves  or  chiasm,  and  consist 
of  optic  atrophy,  amblyopia,  loss  of  color  sense,  etc.;  the  Argyll-Robertson 
pupil  may  be  present.' 

The  speech  is  characteristic,  being  the  so-called  syllabic  utterance  or 
scanning  speech,  in  which  the  syllables  are  separated  by  prolonged  pauses;  the 
protruded  tongue  trembles  and  there  may  be  difficulty  in  swallowing. 

While  varying  degrees  of  hemiplegia  are  not  uncommon,  there  is  no  mus- 
cular atrophy;  disturbances  of  cutaneous  sensation  are  rare  and  if  present  are 
very  slight. 

Headache  and  dizziness  are  sometimes  observed  and  apoplectiform  or 
epileptiform  attacks  may  occur.  The  mind  is  little  if  at  all  disordered, 
although  the  memory  may  be  slightly  impaired;  the  intellect  is  sometimes 
dull  and  there  may  be  paroxysmal  attacks  of  laughing  or  weeping. 

Vesical  disturbance  and  sexual  weakness  are  not  uncommon. 

The  course  of  the  disease  is  variable,  at  times  steadily  progressing  for  a 
year  or  two  until  it  reaches  a  more  or  less  permanent  stage  which  may  last 
for  a  number  of  years;  at  other  times  the  course  may  be  characterized  by 
remissions  but  there  is  no  hope  of  ultimate  recovery. 


742  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  prognosis  as  regards  the  patient's  life  is  most  serious  in  those  cases  in 
which  the  sclerosis  affects  those  portions  of  the  nervous  system  in  which  the 
vital  centers  are  located — particularly  the  pons  and  medulla. 

Treatment.  We  have  no  means  by  which  we  can  check  the  development 
of  or  cause  to  disappear  the  sclerotic  patches;  consequently  the  treatment  is 
chiefly  symptomatic  and  sustaining.  The  administration  of  mercury  and  potas- 
sium iodide  should  be  instituted  in  all  instances  and  may  even  benefit  patients 
in  whom  there  is  no  history  of  syphilis.  The  hypodermatic  employment  of 
arsenic  and  the  use  of  silver  nitrate  internally  have  been  recommended. 

Tonics  should  be  prescribed  and  the  patient  should  lead  a  quiet,  regular 
life  in  accordance  with  the  rules  of  general  hygiene;  his  diet  should  be 
nourishing  and  easily  digestible.  Massage,  exercises,  hydrotherapeutic 
measures  and  electricity  may  prove  useful  both  in  treating  the  disease  and  in 
giving  the  patient  something  to  take  his  mind  from  his  condition. 

ABSCESS  OF  THE  BRAIN. 

Synonyms.     Suppurative  Encephalitis;  Cerebritis. 

Definition.  A  collection  of  pus  or  purulent  fluid  within  the  substance  of 
the  brain  or  between  it  and  its  meninges. 

.Etiology.  Like  abscesses  of  other  parts,  those  of  the  brain  are  the  result 
of  bacterial  infection.  The  pathogenic  micro-organisms  find  lodgment  as 
a  result  of  a  traumatism,  as  a  result  of  an  adjacent  purulent  process  spreading 
to  the  brain  tissue  or  they  may  be  brought  from  a  distance  by  the  blood  stream 
as  in  pyaemia. 

Males  are  most  frequently  affected  and  the  most  susceptible  age  is  between 
ten  and  forty  years. 

Following  injury,  such  as  a  compound  cranial  fracture,  the  abscess  may 
develop  as  a  result  of  infection  of  the  open  wound;  after  contre  coup  fractures 
the  abscess  may  involve  the  tissues  opposite  or  beneath  the  site  of  the  trauma. 

The  most  frequent  cause  of  brain  abscess  is  middle  or  internal  ear  disease, 
especially  when  the  tympanic  cavity  or  mastoid  cells  are  affected.  Infective 
processes  of  the  nasal  and  orbital  cavities  also  may  result  in  brain  abscess. 

Pyaemia  is  a  much  less  frequent  cause;  malignant  endocarditis,  tuberculous 
inflammations  of  the  lungs,  empyema,  hepatic  abscess,  gangrene  of  the  lungs, 
etc.,  may  produce  abscess  of  the  brain  and  the  condition  may  complicate  the 
infectious  fevers,  enteric  fever,  smallpox,  epidemic  influenza,  erysipelas  and 
the  like. 

Pathology.  There  is  usually  but  one  abscess  although  there  may  be  two 
or  more.  The  most  frequent  location  for  those  resulting  from  injury  is  in 
the  frontal  or  temporal  lobes,  those  from  nasal  or  orbital  disease  in  the  frontal 


ABSCESS    OF    THE    BRAIN.  743 

lobe,  those  from  otitic  inflammations  in  the  cerebellum;  embolic  abscesses  are 
most  commonly  situated  in  the  parts  supplied  by  the  middle  cerebral  artery. 
The  first  change  is  a  marked  congestion  which  results  in  red  softening.  The 
process  continuing,  the  tissues  become  infiltrated  with  inflammatory  exudate 
and  leucocytes.  The  resulting  pus  is  greenish-yellow  in  color  and  of  acid 
reaction  and  consists  of  pus  cells,  disintegrated  nerve  fibres  and  cells,  bac- 
teria and  granular  detritus.  The  abscess  varies  in  diameter  from  one-third 
of  an  inch  to  three  inches,  and  is  surrounded  by  a  fibrous  wall  con- 
sisting of  an  inner  layer  composed  of  fatty  granular  cells,  a  middle  layer 
of  germinal  and  fibrous  tissue  and  an  outer  of  fatty  cells.  Abscesses  with  no 
such  distinct  wall  may  occur;  these  are  more  prone  to  spread  than  the  encapsul- 
ated variety.  Abscesses  near  the  surface  of  the  brain  may  produce  meningitis 
by  extension.     Ruptiure  of  an  abscess  wall  may  take  place,  death  resulting. 

Certain  instances  of  cerebritis  do  not  proceed  farther  than  the  stage  of  red 
softening,  the  exudate  being  absorbed  and  recovery  ensuing  with  the  formation 
of  an  apoplectic  cyst  or  a  cicatrix. 

Symptoms.  The  course  of  abscess  of  the  brain  may  be  either  acute  or 
chronic;  in  the  former  type  the  disease  runs  its  course  within  a  few  days. 
The  symptoms  are  those  of  increased  intracranial  pressure,  such  as  headache, 
dizziness,  vomiting  and  mental  hebetude  or  delirium,  followed  by  coma. 
Epileptiform  convulsions  may  occur  but  are  rather  infrequent;  the  pupils 
may  be  unequal.  Toxic  symptoms  are  superadded  to  those  of  pressure  and 
are  those  usually  seen  in  septic  conditions,  such  as  an  irregular  temperature 
curve,  usually  not  every  high,  sometimes  subnormal,  chills,  prostration  and 
emaciation.  The  pulse  is  usually  slow — from  60  to  70.  Symptoms  of  local 
irritation,  such  as  paralyses  or  aphasia,  are  not  infrequent ;  symptoms  referable 
to  the  cranial  nerves,  except  the  optic — optic  atrophy  not  being  uncommon — 
are  rare. 

The  symptoms  of  the  chronic  type  are  the  same  as  those  discussed  above 
but  they  develop  much  more  slowly.  Even  after  the  abscess  has  been  formed 
there  may  be  remissions  during  which  the  symptoms  remain  latent  although 
headache,  irritability,  dizziness  and  mild  convulsions  may  persist.  The  periods 
of  remission  may  be  interspersed  with  exacerbations  of  the  symptoms.  After 
months  of  such  alternation  the  terminal  period  begins;  here  the  symptoms  are 
those  of  the  acute  type  of  rapid  course  and  are  quickly  followed  by  death  in 
coma.  This  rapid  termination  is  due  to  rupture  of  the  abscess  or  haemorrhage 
into  it.  Instances  of  abscess  of  the  frontal  lobe  have  gone  to  autopsy  without 
the  lesion  having  been  suspected. 

Complications  such  as  phlebitis  of  the  superior  petrosal  and  lateral  sinuses 
are  frequent  in  abscess  due  to  middle  ear  disease;  meningitis  is  more  likely  to 
complicate  instances  due  to  trauma.  In  the  former  the  symptoms  of  the  com- 
plication are  oedema  of  the  tissues  about  the  ear  and  of  the  neck,  with  hardness 


744  DISEASES    OF    THE    NERVOUS    SYSTEM. 

of  the  jugular  veins;  meningitis  is  evidenced  by  stillness  of  the  neck  and 
cranial  nerve  involvement. 

The  prognosis  is  uniformly  bad  unless  the  seat  of  the  disease  can  be  reached 
by  surgical  means. 

Treatment.  Prophylaxis  consists  in  the  proper  management  of  nasal  and 
aural  lesions  and  attention  to  the  cleanliness  of  all  cranial  injuries.  Further 
than  this  the  treatment  is  purely  surgical  and  consists  in  trephining  the  skull 
and  evacuating  the  abscess.  For  the  technique  of  this  procedure  the  reader 
is  referred  to  works  upon  surgery. 

TUMORS  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

Among  the  neoplasms  affecting  the  brain  alone  are  classed  also  all  tumors 
within  the  cranium  and  those  external  to  the  cranial  cavity  which*  subse- 
quently, by  extension,  affect  the  brain,  such  as  those  of  the  orbit,  of  the  nasal 
cavity  and  of  the  neighboring  fossae. 

Varieties.  Of  these  the  most  common  is  the  tuberculoma  or  tuberculous 
tumor,  next  in  order  of  frequency  is  the  glioma  and  following  these  in  order 
of  frequency  afre  the  sarcomata,  carcinomata,  cystic  tumors,  including  those 
due  to  the  echinococcus  and  the  cysticercus  cellulosas,  and  gummata.  All 
the  other  varieties  of  neoplasm  occur  in  th^  brain,  such  as  lipomata,  myxomata, 
fibromata,  osteomata,  cholesteatomata,  psammomata,  etc.,  but  those 
mentioned  above  are  most  commonly  met.  Of  these  only  gliomata  and 
psammomata  occur  nowhere  but  in  nerve  tissue. 

.Etiology.  Brain  tumors  seem  to  be  more  common  in  the  male  sex  and 
are  seen  at  all  ages.  Tuberculous  tumor  is  more  frequent  in  children,  while 
late  in  life  carcinoma  is  the  usual  type  of  neoplasm.  During  adolescence  and 
early  adult  life  we  meet  gummata,  sarcomata,  gliomata  and  parasitic  tumors. 
Metastatic  tumors  are  rare  and  are  chiefly  carcinomata.  In  the  production 
of  new  growths  of  the  brain  heredity  has  little  influence.  As  an  exciting 
cause  trauma  may  occasionally  be  a  factor. 

The  portions  of  the  brain  most  frequently  involved  are  the  base  of  the 
cerebrum  and  the  cerebellum  (tuberculoma);  the  hemispheres  and  pons 
(gumma);  the  cerebral  substance  near  its  surface  and  the  ventricles  (cystic 
tumors),  the  pineal  gland  (psammoma).  Glioma  is  seen  in  the  retina  spread- 
ing to  the  cerebrum  or  may  develop  primarily  in  this  site;  sarcoma,  carcinoma, 
myxoma  and  fibroma  affect  the  meninges;  sarcoma,  mucous  and  fibrous 
tumors  occur  in  the  sheaths  of  the  vessels,  while  carcinoma  at  times  is 
found  in  the  substance  of  the  hemispheres. 

Symptoms.  These  are  chiefly  due  to  pressure  and  vary  with  the  situation 
of  the  tumor.  Of  general  symptoms,  one  of  the  earliest  and  most  prominent 
is  headache,  usually  constant  but  with  intensely  severe  exacerbations;  at 


TUMORS    OF    THE    BRAIN    AND    ITS    MEMBRANES.  745 

times  it  may  intermit.  Vomiting,  often  without  nausea,  may  accompany 
the  headache  or  occur  independently;  it  may  be  of  projectile  type.  Vertigo 
is  frequent  and  varies  in  degree;  it  may  be  slight  or  so  marked  as  to  interfere 
with  walking  or  standing. 

Mental  symptoms  such  as  irritability,  loss  of  memory,  absent-mindedness, 
dulness,  drowsiness  and,  at  times,  coma,  may  be  present  or  conditions  of 
excitement  or  delirium  may  be  manifest. 

Speech  defects,  most  commonly  a  running  together  of  the  syllables,  may 
occur. 

Epileptiform  or  apoplectiform  attacks  (see  Jacksonian  epilepsy,  p.  823) 
are  characteristic  symptoms.  Choreiform  twitchings  may  be  observed. 
True  apoplexy  may  take  place  from  rupture  of  a  blood-vessel  in  or  near  the 
tumor. 

Optic  neuritis  is  one  of  the  most  important  symptoms  from  a  diagnostic 
point  of  view.  It  occurs  in  a  large  majority  (80  percent.)  of  patients,  its 
course  is  progressive  and  it  terminates  in  optic  atrophy;  it  is  usually  bilateral 
but  the  nerve  of  one  side  may  be  involved  before  that  of  the  other.  Choked 
disc  is  not  infrequent. 

Sensory  disorders  such  as  pruritus,  derangements  of  tactile  sensation 
and  neuralgic  pains,  as  well  as  disturbances  of  the  special  senses,  may  occur. 

Urinary  abnormalities  (polyuria  or  glycosuria)  may  be  observed  if  the 
tumor  involves  the  floor  of  the  fourth  ventricle. 

As  the  disease  goes  on  the  appetite  and  the  nutrition  suffer,  though  more 
rarely  these  manifestations  are  absent,  and  as  the  patient  nears  death  the 
pulse  may  become  slow,  the  breathing  irregular  and  the  temperature 
elevated. 

The  observance  of  symptoms  referable  to  the  situation  of  the  neoplasm  is 
important  particularly  from  a  standpoint  of  diagnosis.  In  order  to  systemat- 
ize the  different  symptoms  which  may  occur  as  a  result  of  tumor  occurring 
in  different  localizations,  the  brain  has  been  divided  (Dana)  as  in  Fig.   11. 

a.  The  prefrontal  area  may  be  considered  as  that  portion  of  the  brain 
anterior  to  a  line  drawn  at  right  angles  to  another  drawn  through  the  frontal 
and  occipital  extremities  of  the  brain  and  beginning  at  the  upper  end  of  the 
ascending  branch  of  the  Sylvian  fissure. 

b.  The  central  region  includes  that  portion  of  the  cerebrum  between  the 
line  described  above  and  another,  limiting  the  posterior  central  convolution 
prolonged  downward  to  the  fissure  of  Sylvius. 

c.  The  parietal  lobe. 

d.  The  occipital  lobe. 

e.  The  temporal  or  temporosphenoidal  area. 
/.  The  pons  and  medulla. 

g.  The  cerebellum. 


746 


DISEASES    OF    THE    NERVOUS    SYSTEM 


Other  situations  not  included  below  are: 

h.  The  corpus  callosum. 

i.  The  basal  ganglia  and  capsules. 

/.  The  corpora  quadrigemina  and  pineal  gland. 

k.  The  crura  cerebri. 

/.  The  base  of  the  cerebrum. 

Tumors  situated  in  the  prefrontal  area  may  cause  no  localizing  symptoms, 
particularly  if  on  the  right  side,  and  even  general  symptoms  may  be  lacking. 
In  other  instances  the  latter  may  be  plainly  evident,  emotional  disturbances, 

2.  Localized  spasms  and  epilepsy,  with 
sensory  aurse;  local  palsies,  slight  an- 
aesthesia, motor  aphasia,  agraphia. 


1.  No  symp- 
toms or  men- 
tal dulness,ir- 
ri  t  a  b  i  1  i  t  y  , 
childishness, 
lack  of  power 
of  attention; 
later,  motor 
spasms  or  pa- 
ralysis, anos- 
m  i  a ,  eye 
s  y  m  p  toms. 
P  e  re  u  s  sion 
tenderness. 


Ascending  | 
limb  of  fis 
sure      of  I 

Sylvius. 


Word 
deaf- 
ness, 
no 

symp- 
toms. 


Crossed  paral- 
ysis of  III.  IV 
and  limbs. 

6.  Crossed  paraly- 
sis of  Vand  limbs. 


3.  No    symptoms   or   mus- 
cular  anaesthesia,   aprax- 
^ia,     oculomotor     ("third 
nerve)    symptoms, 
word     blindness. 
With   deep  lesions, 
anaesthesia;  if   the 
lesion  penetrates 
sufficiently 
deep,  hemian- 
opsia. 


4.  Hemian- 
opsia, word- 
fa  1  i  n  d  n  ess, 
and  m  i  n  d- 
blindness. 


7.      Cerebellar 
ataxia,     vertigo, 
vomiting,    forced 
movements,    occi- 
pital headache;  later 
zontal  L  /  bulbar  symptoms. 
!^F.  of  S. 


6.  Crossed  paralysis 
of  tongue  and  limbs; 
bulbar  palsy. 

Fig.  II.  — Showing  focal  symptoms  of  brain  turaor— (after  Dana). 


mental  stupidity  and  irritability  being  present  in  affections  of  either  hemis- 
phere. Aphasia  may  occur  if  the  lesion  involves  the  inferior  frontal  convo- 
lution and  spasm  or  destructive  paralysis  may  result  if  the  tumor  extends 
posteriorly.  Hemianopsia  and  optic  neuritis  may  be  caused  by  involvement 
of  the  optic  tract;  disturbance  of  the  sense  of  smell  by  involvement  of  the 
olfactory  centers.  Invasion  of  the  orbit  results  in  oculomotor  palsy  and 
exophthalmos.  There  may  be  tenderness  on  percussion  over  the  neoplasm. 
Tumors  of  the  central  region  may  cause  spastic  symptoms.  If  in  the  upper 
part  of  this  region  spasm  of  the  toes,  ankles  or  legs;  if  in  the  middle  third  the 
spasm  begins  in  the  fingers,  forearm  or  shoulder;  if  in  the  anterior  third  the 


TUMORS    OF    THE    BRAIN    AND    ITS    MEMBRANES.  747 

facial  muscles  or  tongue  are  affected.  With  the  spasmodic  symptoms  there 
may  be  numbness  or  tingling,  beginning  in  a  certain  group  of  muscles.  Mus- 
cular sense  may  be  disturbed. 

Tumors  0/  the  parietal  lobe  may  be  accompanied  by  no  symptoms  but  stereag- 
nostic  perception  may  be  affected;  word  and  mind  blindness  may  be  associated 
with  involvement  of  the  angular  gyrus  and  inferior  parietal  lobule.  Third 
nerve  paralysis  has  been  observed  in  tumors  near  the  angular  gyrus,  though 
this  symptom  is  difficult  of  explanation. 

If  the  tumor  extends  to  the  central  region  motor  symptoms  may  occur. 

Tumors  of  the  occipital  lobe  involving  the  cuneus  may  cause  homonymous 
hemianopsia  if  unilateral,  complete  blindness  if  bilateral.  In  tumor  of  other 
portions  of  the  left  lobe  mind  blindness  may  result,  while  if  the  angular  gyrus  is 
involved  the  hemianopsia  may  be  associated  with  word  blindness.  Ac- 
companying extension  forward  into  the  parietal  lobe  there  may  be  hemataxia, 
hemianagsthesia  and  possibly  partial  hemiplegia. 

Tumors  of  the  temporosphenoidal  lobe  may,  when  in  the  posterior  part  of 
the  first  and  in  the  posterior  superior  part  of  the  second  gyrus,  be  evidenced 
by  word  deafness;  if  on  the  right  side  they  usually  are  without  symptoms. 
In  involvement  of  the  hippocampal  convolution  there  may  be  disorders  of 
smell  and  taste. 

Tumors  of  the  pons  and  medulla  cause  either  irritation  or  destruction  of  the 
fibres  of  these  structures  or  symptoms  due  to  pressure.  At  times  both  these 
consequences  result.  Neoplasms  in  this  vicinity  are  likely  to  produce  symp- 
toms involving  the  face  on  one  side  and  the  body  upon  the  other. 

Accompanying  lesions  of  the  peduncle  of  the  cerebrum  there  may  be  third 
nerve  paralysis  on  the  side  of  the  lesion  and  hemiplegia  of  the  other  side. 
In  lesions  below  this  point  and  involving  the  pons,  paralysis  of  the  fifth  nerve 
of  the  same  side  and  hemiplegia  of  the  opposite  side  may  result.  Sixth  nerve 
involvement  with  internal  strabismus  may  be  associated  with  tumors  still 
lower  down  and  also  facial  palsy  and  deafness  due  to  involvement  of  the 
seventh  and  eighth  nerves  may  occur.  In  tumors  of  large  size,  hemiansesthesia 
and  forced  movements  of  the  body  and  conjugate  deviation  of  the  eyes  away 
from  the  affected  side  may  be  present. 

In  neoplasms  of  the  medulla  there  may  be  hemiplegia;  hemianaesthesia 
and  bulbar  symptoms  may  occur.  Irritation  of  the  nuclei  of  the  ninth, 
tenth,  eleventh  and  twelfth  nerves, which  have  their  origin  in  this  structure,  may 
also  result,  being  evidenced  by  dysphagia,  irregular  cardiac  action  and  res- 
piration, and  vomiting.  Retraction  of  the  head,  numbness,  tingling,  and 
even  convulsions  may  be  present.  Pressure  on  the  cerebellum  causes  dis- 
orded  coordination  and  a  staggering  gait. 

Tumors  of  the  cerebellum  are  evidenced  by  very  typical  symptoms  which 
are  described  in  detail  on  p.  750, 


748  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Tumors  oj  the  corpus  callosum  cause  symptoms  analogous  to  those  due  to 
involvement  of  the  third  and  lateral  ventricles.  There  are  no  symptoms  refer- 
able to  the  cranial  nerves,  but  mental  hebetude  and  stupor,  hemiplegia  of 
gradual  development  and  linally  paraplegia  are  likely  to  be  present. 

Tumors  0}  the  basal  ganglia  and  internal  capsule  cause  symptoms  resem- 
bling those  of  lesions  of  the  corpus  callosum,  such  as  gradually  increasing 
hemiplegia  with  accompanying  hemianaesthesia  and,  if  the  tumor  involves 
the  optic  thalamus  and  neighboring  portions  of  the  internal  capsule,  athetoid 
and  choreiform  movements  may  be  present.  Tumors  involving  the  anterior 
portions  of  the  optic  thalamus  may  also  be  evidenced  by  these  movements 
while  those  of  the  lenticular  or  candate  nuclei  alone  are  usually  without  sym.p- 
toms.  If  very  large,  however,  tumors  of  the  thalamus  may  produce  hemi- 
anopsia or  hemianaesthesia,  and  neuritis  of  the  optic  nerve  is  often  an  early 
symptom. 

Tumors  of  the  corpora  quadrigemina  alone  are  rare,  there  being  usually 
associated  involvement  of  the  crura.  They  are  evidenced  by  disturbance 
of  coordination,  forced  movements  and  oculomotor  paralyses,  with  nystag- 
mus and  loss  of  pupillary  r.efiexes;  hemianopsia  or  complete  blindness  may 
also  be  present.  Tianors  0}  the  crura  are  rarely  met.  They  may  cause 
oculomotor  palsy  on  the  same  side,  due  to  third  nerve  involvement,  and 
hemiplegia  of  the  opposite  side. 

Tumors  of  the  base  of  the  brain,  when  in  the  anterior  fossa,  are  accompanied 
by  symptoms  very  similar  to  those  caused  by  tumors  of  the  prefrontal  area 
with  the  addition  of  loss  of  the  sense  of  smell  resulting  from  involvement 
of  the  olfactory  lobe.  Distiirbance  of  the  second  and  third  nerves  may  also  be 
present.  Neoplasms  of  the  middle  fossa  and  interpeduncular  space  press 
upon  the  optic  chiasm  and  are  consequently  accompanied  by  optic  neuritis 
and  bitemporal  hemianopsia. 

The  presence  of  a  tumor  may  be  suspected  from  the  general  symptoms, 
its  situation  from  the  focal  manifestations.  The  Rontgen  ray  has  been 
employed  in  the  diagnosis  of  the  condition  and  at  times  has  given  brilliant 
results  although  the  failures  have  been  in  the  majority.  Possibly  further 
perfection  of  this  means  of  diagnosis  may  produce  successes  with  greater 
uniformity. 

The  prognosis.  Tumors  of  the  brain  due  to  syphilis  may  be  benefited  by 
medical  treatment.  Gliomata  and  fibromata  may  continue  to  grow  slowly  for  a 
number  of  years  and  tuberculous  neoplasms  at  times  cease  increasing  in  size 
and  undergo  calcareous  degeneration.  Malignant  tumors  may  cause  death  in 
a  year  or  two,  death  either  being  sudden,  due  to  involvement  of  the  fourth  ven- 
tricle, or  preceded  by  gradually  increasing  coma  due  to  progressively  augment- 
ing intra-cranial  pressure. 

Treatment  consists  in  regulating  the  patient's  mode  of  life  within  strict 


CEREBELLAR    DISEASE.  749 

hygienic  limitations.  The  use  of  alcohol,  sexual  over-indulgence  and  all 
causes  of  excitement  should  be  avoided  since  any  influence  tending  to  cause 
cerebral  hyperaemia  may  result  fatally.  These  considerations  should  be  kept 
in  mind  in  dealing  with  all  varieties  of  cerebral  neoplasm,  as  well  as  the  fact 
that  the  exhibition  of  general  tonic  treatment  is  indicated. 

In  growths  of  suspiciously  syphilitic  character,  as  well  as  in  all  others  in 
which  the  type  of  the  lesion  is  uncertain,  antisyphilitic  treatment  should  be 
administered.  Cerebral  gummata  are  readily  and  rapidly  absorbed  by  this 
means.  This  treatment  may  be  prescribed  in  the  form  of  mercurial  inunc- 
tions and  the  internal  administration  of  potassium  iodide  in  increasing  doses 
or  the  syrup  of  hydriodic  acid  in  doses  of  i  drachm  (4.0)  three  times  a  day. 
Both  the  mercury  and  the  iodide  should  be  given  to  the  limit  of  the  patient's 
tolerance.  The  mercury  may  also  be  given  in  the  form  of  the  bichloride,  y  2" 
of  a  grain  (0.005)  three  times  a  day  or  hypodermatically  (the  salicylate  i 
grain — 0.065 — suspended  in  benzoinol).  When  the  tumor  appears  to  have 
ceased  increasing  in  size  the  mercury  may  be  stopped  but  the  iodide  should 
be  continued  in  suflacient  dosage  to  control  the  growth. 

Tuberculous  tumors  necessitate  the  employment  of  the  usual  means  indi- 
cated in  tuberculous  conditions,  such  as  iron,  codliver  oil,  etc.,  and  here  partic- 
ularly, proper  diet,  out-door  life  and  attention  to  the  patient's  general  hygiene 
should  be  insisted  upon. 

For  the  headache  the  bromides,  antipyrine,  antipyrine  salicylate  (salipy- 
rine)  or  acetphenetidine  (phenacetine)  may  be  employed.  The  ice  cap  or 
the  application  of  leeches  is  also  useful  in  this  connection  and  if  occipital, 
the  pain  may  be  relieved  by  the  application  of  the  actual  cautery  to  the  nape. 

In  the  light  of  the  advances  which  surgery  and  cerebral  localization  have 
made  of  late  years  operative  procedures  may  be  employed  with  comparatively 
slight  danger.  Success  is  most  likely  to  be  attained  in  sarcomata  and  fibro- 
mata involving  the  dura  and  in  neoplasms  of  the  cerebellum.  Even  if  the 
growth  is  not  found,  or  proves  to  be  impossible  of  removal,  the  operation,  since 
it  relieves  the  intra-cranial  pressure,  may  result  in  material  benefit  to  the 
patient. 

CEREBELLAR  DISEASE. 

While  the  cerebellum  may  be  the  seat  of  disease  of  considerable  extent 
without  symptoms  to  suggest  the  lesion,  affections  of  certain  portions  of  this 
structure,  namely  its  central  lobe  and  vermiform  process,  are  characterized 
by  very  typical  manifestations. 

Tumor  is  the  most  common  cerebellar  lesion,  neoplasms  of  various  character, 
such  as  sarcoma,  tuberculoma,  glioma,  cystic  tumors,  gumma,  etc.,  having 
been  observed.  Abscess  and  haemorrhage  may  occur  but  these  conditions 
are  very  much  rarer. 


750  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  principal  symptoms  of  cerebellar  disease  are  disordered  gait,  vertigo 
and  headache. 

The  gait  is  uncertain,  the  patient  reels  and  stumbles  to  one  side  or  the  other, 
forward  or  backward,  very  much  after  the  manner  of  a  drunken  man.  He 
is  likely  to  walk  with  the  feet  wide  apart,  for  this  diminishes  the  tendency  to 
stagger.  Muscular  sense  remains  normal,  consequently  there  is  no  Romberg 
symptom.     The  arms  and  body  are  seldom  affected. 

The  vertigo  varies  in  degree,  is  not  constant  and  may  occur  independently 
of  the  gait  disturbance.  It  is  most  marked  when  the  patient  is  standing 
or  walking  and  is  very  greatly  diminished  or  absent  entirely  when  he  is  sitting 
or  lying.     If  of  severe  type  it  is  a  most  distressing  symptom. 

Headache  is  frequent;  in  most  patients  it  is  occipital,  while  less  frequently 
the  pain  may  be  in  the  temporal  or  frontal  regions. 

Other  symptoms  suggestive  of  cerebellar  disease  are  vomiting,  spasmodic 
movements  of  the  eyes,  optic  neuritis  which  may  go  on  to  atrophy  and  blind- 
ness, and  neuralgic  pains  at  the  back  of  the  head  and  neck.  The  knee  jerks 
are  often  exaggerated  but  may  be  entirely  absent.  More  rarely  effusion ' 
into  the  ventricles  resulting  from  obstruction  of  the  venae  Galeni,  symptoms 
referable  to  pressure  upon  the  medulla  and  the  origins  of  the  cranial  nerves, 
glycosvuia,  rigidity  of  both  sides  of  the  body  from  pressure  interference  with 
the  paths  of  the  motor  nerves  and  sudden  death  from  involvement  of  the 
medullary  centers  may  occur. 

Forced  positions  may  accompany  lesions  of  the  middle  peduncles  of  the 
cerebellum.  Wlien  these  are  present  the  patient  assumes  a  position  in  bed 
and,  when  moved,  unconsciously  reassumes  this  posture;  constant  positions 
of  the  head  and  eyes  may  be  associated  with  this  symptom. 

Forced  movements  may  be  present;  these  consist  of  a  turning  of  the  body 
about  its  longitudinal  axis  or  a  tendency  to  walk  in  circles. 

DISEASES  INVOLVING  CHIEFLY  THE  SPINAL  CORD  OR  ITS 

MEMBRANES. 

ACUTE  AND  CHRONIC  MYELITIS. 

Definition.  An  acute  inflammation  of  the  spinal  cord.  Acute  myelitis 
differs  from  the  subacute  and  chronic  forms  of  the  inflammation  merely  in 
rapidity  of  development  of  symptoms,  consequently  as  far  as  aetiology  and  path- 
ology are  concerned  the  different  types  will  be  discussed  as  one.  As  the  inflam- 
mation involves  different  extents  of  the  cord,  to  it  different  terms  are  applied; 
transverse  myelitis,  when  an  entire  cross  section  of  the  cord  is  affected ;  diffuse 
when  a  large  extent  vertically  is  diseased;  focal  when  but  one  small  area  is 


ACUTE    AND    CHRONIC    MYELITIS.  75 1 

involved;  disseminated  when  the  disease  affects  a  number  of  small  areas; 
central  when  the  gray  substance  about  the  central  canal  is  inflamed. 

^Etiology.  The  disease  is  met  at  all  ages  but  more  frequently  in  males. 
It  may  occur  as  a  result  of  exposure  to  the  inclemencies  of  the  weather,  follow- 
ing injuries,  such  as  contusions,  strains  or  fractures  of  the  spinal  column, 
secondary  to  sepsis  and  the  infectious  diseases,  as  a  result  of  syphilis  or  of 
disease  of  the  vertebrae.  Many  of  these  factors  cause,  lirst,  a  mechanical  in- 
jury which  is  followed  by  inflammation  as  a  secondary  manifestation. 

The  most  common  site  of  the  lesion  is  the  upper  dorsal,  the  most  infrequent 
the  lumbar  region. 

Pathology.  The  spinal  cord  is  at  first  intensely  congested,  reddish-brown 
in  color,  softer  in  consistency  than  normal,  and  the  distinction  between  white 
and  red  matter  is  less  marked;  tiny  haemorrhages  may  be  visible,  their  sites 
later  becoming  cavities;  later  in  the  acute  type,  the  color  changes  to  yellowish 
or  white,  the  affected  area  is  infiltrated  with  serous  fluid  and  becomes  softened 
and  degenerated.     The  meninges  also  are  the  seat  of  morbid  change. 

The  microscope  reveals  the  presence  of  extra vasated  red  cells  and  leucocytes, 
of  the  latter,  however,  but  a  few;  in  places  the  nerve  tissue  has  wholly  disap- 
peared, in  others  degenerated  axis-cylinders  without  medullary  sheaths  niay 
remain;  the  ganglion  cells  may  be  entirely  destroyed  or  are  of  rounder  outline 
and  without  processes.  As  the  nerve  tissue  is  destroyed  its  place  is  taken 
by  neuroglia,  the  cells  of  which  increase  in  number.  Deiter's  cells  may  be 
present,  as  also  may  granular  fatty  cells,  and  the  walls  of  the  enlarged  blood- 
vessels are  the  seat  of  hyaline  degeneration.  Where  the  normal  cord  sub- 
stance has  been  replaced  by  neurogha  tissue,  no  regeneration  is  possible,  the 
change  being  permanent 

Symptoms.  The  onset  of  myelitis  may  be  sudden  with  a  chill,  followed 
by  a  rise  in  temperature,  io3°-io4°  F.  (39.5°-4o.°  C.)  or  even  higher,  rapid 
pulse,  headache  and  prostration,  or  there  may  be  prodromal  symptoms 
such  as  numbness  or  other  paraesthesiae  in  the  back  and  extremities.  More 
rarely  is  the  disease  ushered  in  by  convulsions. 

The  typical  symptoms  differ  so  markedly  with  the  portion  of  the  spinal  cord 
affected  that  it  is  considered  best  to  discuss  those  likely  to  be  met  in  most 
cases  and  later  those  which  are  characteristic  of  the  various  areas  of  the  cord 
usually  involved. 

a.  The  symptoms  of  motor  irritation.  These  are  seen  both  at  the  onset 
and  during  the  progress  of  the  disease  and  consist  of  convulsive  movements, 
either  quick  or  slow,  of  the  muscles  of  the  legs. 

b.  The  symptoms  of  motor  paralysis.  These  appear  early  and  are  the 
first  symptoms  to  suggest  the  diagnosis;  they  consist  of  a  weakness  and  loss 
of  power  in  the  legs,  progressing  until  total  paraplegia  is  present.  If  one 
leg  is  less  affected  than  the  other,  the  inflammation  is  less  general  in  the  corre- 


752  DISEASES    OF    THE    NERVOUS    SYSTEM. 

spending  half  of  the  cord.  In  lumbar  or  dorsal  myelitis  only  the  lower  limbs 
are  paralyzed;  in  myelitis  of  the  cervical  region  all  four  extremities  are  paral- 
yzed. 

c.  Sensory  disturbances  are  late  symptoms.  Early  in  the  course  of  the 
disease  there  is  rarely  pain,  but  numbness  and  tingling  of  the  extremities, 
and  at  times  the  girdle  sensation  may  be  present.  The  sense  of  touch  remains 
normal  except  at  very  late  stages  of  the  affection  when  anaesthesia  is  the  rule, 
although  hyperaesthesia  or  parsesthesias  may  be  present.  Sensory  disturbances 
aid  us  in  diagnosticating  the  level  of  the  lesion  since  their  upper  limit  corre- 
sponds in  fair  degree  to  the  site  of  the  inflammation. 

d.  Reflex  disturbances.  These  differ  with  the  site  of  the  lesion  and  with 
the  extent  of  cord  involved.  In  lumbar  myelitis  the  skin  reflexes  are  dimin- 
ished over  the  legs;  in  dorsal  or  cervical  myelitis  when  the  lumbar  cord  is 
intact,  the  cutaneous  reflexes  of  the  legs  may  be  normal  or  increased,  owing 
to  the  fact  that  the  lumbar  reflex  arc  is  unaffected  and  the  possibility  of  inter- 
ference with  the  inhibition.  At  times,  however,  these  reflexes  may  be  dimin- 
ished even  in  dorsal  or  cervical  lesions. 

The  patellar  reflex  and  ankle  clonus  are  absent  when  the  lumbar  cord  is 
extensively  diseased  and  the  former  is  lost  when  the  inflammation  involves 
the  lateral  posterior  columns  and  the  anterior  horns  in  this  region.  When 
the  cord  above  the  lumbar  region  is  affected,  the  tendon  reflexes  of  the  legs 
are  increased  owing  to  the  interference  with  the  passage  of  inhibitory  impulses. 
A  lesion  involving  the  entire  cord  in  the  dorsal  or  cervical  region  may  be 
accompanied  by  a  loss  of  the  reflexes  in  the  lower  extremities.  When  the 
inflammation  is  confined  to  the  cervical  region,  the  tendon  reflexes  of  the 
arms  may  be  exaggerated. 

e.  Bladder  and  rectal  disturbances.  Early  in  the  disease  both  micturition 
and  defaecation  are  delayed,  later  there  is  retention  of  urine  and  ultimately 
the  bladder  and  rectum  become  incontinent. 

/.  Trophic  and  vaso-motor  disturbances.  When  the  lesion  is  in  the  dorsal 
or  cervical  cord  there  is  no  wasting  of  the  paralyzed  muscles  of  the  legs,  but 
when  the  lumbar  cord  is  involved,  atrophy  takes  place  and,  if  the  anterior 
horns  or  nerve  roots  of  the  cervical  region  are  diseased,  the  same  condition 
occurs  in  the  muscles  of  the  arms.  Bed-sores  over  the  buttocks  or  heels 
develop  as  a  result  of  trophic  disorders  and  the  skin  becomes  dry  and  hard 
and  the  nails  brittle. 

Vaso-motor  changes  result  in  mottling  of  the  skin,  oedema  and  hyperi- 
drosis;  the  surface  temperature  of  the  paralyzed  limbs  is  often  subnormal. 

The  electric  reaction  of  the  muscles,  when  these  are  atrophied,  is  changed 
and  the  reaction  of  degeneration  is  present. 

Cervical  myelitis  is  characterized  by  paralysis  of  greater  or  less  extent  in 
the  arms  and  complete  paralysis  of  the  legs;  atrophy  of  all  or  only  certain 


ACUTE    AND    CIir^ONIC    MYELITIS.  753 

groups  of  the  muscles  of  the  arms  while  the  muscles  of  the  legs  remain  of 
normal  size  may  be  noted;  these  latter,  however,  may  become  flaccid  from 
disuse.  The  deep  reflexes  of  both  sets  of  limbs,  or  only  of  the  legs,  are 
exaggerated  and  vesical  and  rectal  disturbances  occur. 

In  dorsal  myelitis,  while  the  upper  limbs  retain  their  normal  state,  the  legs 
are  paralyzed  and  may  be  the  seat  of  sensory  disorders.  If  the  anterior 
cornua  are  involved  there  may  be  muscular  atrophy  and  reaction  of  degener- 
ation; vesical  and  rectal  disturbances  develop  and,  while  the  cutaneous  reflexes 
usually  remain  normal,  the  knee  jerk  is  increased  and  ankle  clonus  is  present. 

In  lumbar  myelitis  the  arms  are  not  affected;  the  legs  are  paralyzed  and 
atrophied  and  the  reaction  of  degeneration  is  observed;  rectal  and  vesical 
disturbances  are  present  and  both  cutaneous  and  deep  reflexes  are  absent. 

The  prognosis.  Rarely  instances  of  very  rapid  development,  causing  death 
in  a  week  or  ten  days,  may  occur.  The  usual  course  of  the  disease  is  chronic 
after  a  more  or  less  acute  onset  and  continues  for  months  and  often  years. 
The  chances  for  improvement  remain  good  up  to  about  a  year  and  a  half 
after  the  beginning  of  the  symptoms;  they  are  less  favorable  when  motor 
disturbances  are  marked  than  in  instances  evidenced  chiefly  by  sensory  disorders; 
they  are  worst  in  cervical  and  best  in  dorsal  lesions.  Death  may  result  from 
exhaustion  or  concurrent  disease. 

Treatment.  During  the  acute  stage  the  patient  must  be  kept  in  bed, 
the  bowels  are  kept  regularly  open  by  means  of  laxatives  and  the  pain  and  local 
congestion  may  be  relieved  by  the  application  of  leeches  or  wet  or  dry  cups 
to  the  spine.  If  cardiac  excitement  or  hypertension  of  the  arterial  system 
is  present  aconite  or  glyceryl  nitrate  should  be  given.  After  the  acute  symp- 
toms have  subsided,  moderate  doses — gr.  viii  to  x  (0.52-0.66) — of  potassium 
iodide  should  be  administered  and  if  there  is  the  least  suspicion  of  syphilis 
as  a  causative  factor  the  patient  should  be  immediately  put  upon  a  course  of 
mercurial  inunctions  and  increasing  doses  of  potassium  iodide.  The  tonics, 
iron,  strychnine  and  quinine  are  useful  as  adjuvants.  If  there  is  no  response 
to  the  antisyphilitic  treatment,  sodium  arsenate  gr .  yV  (0.006)  three  times  a  day, 
elixir  of  phosphorus  i  drachm  (4.0)  three  times  a  day  or  silver  nitrate  gr.  J 
to  ^  (0.016-0.032)  three  times  a  day  may  be  tried.  A  necessary  precaution 
in  the  administration  of  these  drugs  is  a  period  of  intermission  every  two 
to  four  weeks  depending  upon  the  tolerance  of  the  patient.  Gold  chloride 
has  been  recommended  but  there  is  doubt  if  this  or  any  of  the  other  sub- 
stances mentioned  above  can  materially  influence  the  course  of  the  disease. 

Very  important  considerations  are  the  prevention  of  cystitis  and  bed-sores. 
The  disturbances  of  the  bladder  may  be  mitigated  by  the  internal  adminis- 
tration of  tincture  of  hyoscyamus  15  to  20  minims  (i.o  to  1.33),  oleum  santali, 
hexamethylenamine  and  the  various  balsams;  when  catheterization  becomes 
necessary  the  utmost  attention  must  be  given  to  the  asepsis  of  the  procedure. 
48 


754  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Bed-sores  may  be  guarded  against  by  means  of  attention  to  the  cleanliness 
of  the  back  and  limbs  and  of  the  bed,  by  powdering  the  parts  with  talcum, 
tannic  acid  or  lycopodium,  by  bathing  with  alcohol  and  astringent  solutions 
and  by  the  use  of  the  water  bed  when  necessary.  In  the  later  stages  of  the 
disease  it  is  preferable  to  empty  the  bowel  by  irrigation  rather  than  by  purga- 
tives. Electricity  in  the  form  of  galvanism  should  be  employed,  the  electrodes 
being  applied  to  the  vertebral  column  over  the  seat  of  the  lesion.  Both 
faradism  and  the  continuous  current  should  be  administered  to  the  affected 
nerves  and  muscles  of  the  limbs  and  electric  treatment  of  the  bladder  may 
accomplish  good.  Massage  is  an  excellent  means  of  exercising  the  paralyzed 
muscles  and  preventing  wasting,  it  also  improves  the  circulation  and  the 
general  condition  of  the  patient. 

.  Hydrotherapeutic  measures  should  be  employed  with  care,  and  while 
benefit  may  attend  the  use  of  warm  (85°-9o°  F. — 29.5°-32.5°  C.)  full  baths 
or  cooler  (75°-8o°  F. — 24°-27°  C.)  half  baths,  both  with  thorough  frictions, 
cold  baths  and  applications  are  not  advisable.  The  baths  may  be  more 
stimulating  if  salt  is  added  and  sojourns  at  the  various  hot  springs  of  this 
countrv  or  Europe,  when  the  patient  is  able  to  travel,  are  often  beneficial. 

In  the  chronic  stage  of  the  disease  mechanical  appliances  or  tenotomy, 
employed  with  a  view  to  straightening  the  contracted  limbs,  may  be  advised. 
Compression  myelitis  should  be  treated  with  proper  orthopaedic  apparatus 
with  the  object  of  relieving  the  pressure  upon  the  cord  and,  when  the  lesion 
is  the  result  of  vertebral  fracture,  such  surgical  operations  as  laminectomy,  etc., 
may  be  indicated. 

The  diet  of  the  patient  should  be  sustaining  and  easily  digestible  and  assi- 
milable, and  he  should  lead  a  quiet  restful  life,  as  much  in  the  open  air  as  his 
condition  and  the  weather  permit.  Sea  voyages,  when  possible,  are  especi- 
ally to  be  recommended. 

MYELOMALACIA. 

This  is  a  condition  of  the  spinal  cord  resulting  from  an  insufl&cient  blood 
supply  due  to  embolism  or  thrombosis  of  its  nutrient  blood-vessels  and  charac- 
terized by  a  degeneration  of  the  cord  substance.  The  initial  change  consists 
in  a  necrosis  accompanied  by  the  extravasation  of  red  blood  cells  and  leucocytes; 
upon  microscopical  examination  degenerated  nerve  fibres  and  fatty  cells  may 
be  seen  together  with  red  and  white  blood  discs;  later  the  degenerative  nerve 
substance  is  replaced  by  neuroglia  tissue. 

ACUTE  ANTERIOR  POLIOMYELITIS. 

Synonyms.  Infantile  Spinal  Paralysis;  Infantile  Palsy;  Acute  Atrophic 
Paralysis. 

Definition.     An  acute  febrile  disease  characterized  by  paralysis  of  rapid 


ACUTE    ANTERIOR    POLIOMYELITIS,  755 

development,  followed  by  wasting  of  the  muscles  and  without  disturbance 
of  sensation. 

etiology.  This  disease  occurs,  in  by  far  the  majority  of  instances,  in  infancy 
and  childhood.  It  may  be  met  at  all  ages  but  is  rare  after  the  age  of  ten  years. 
It  appears  most  commonly  in  the  warm  months — June  to  September — and 
a  number  of  epidemics  have  been  reported.  Over-exertion  and  chilling  of 
the  body  may  be  contributory  causes  and  the  condition  may  appear  as  a  sequeia 
of  the  infectious  diseases,  especially  measles,  typhoid  fever  and  diphtheria. 
The  specific  cause  of  anterior  poliomyelitis  is  probably  an  infectious  bac- 
terium. 

Pathology.  The  disease  is  one  of  the  anterior  horns  of  the  spinal  cord, 
particularly  in  the  region  of  the  cervical  and  lumbar  enlargements.  It  is 
characterized  by  an  acute  exudative  inflammation,  and  consequent  degenera- 
tion with  replacement  by  connective  tissue,  of  certain  groups  of  cells.  As  a 
result  of  this  process  there  occur  an  atrophy  of  one  or  both  cornua,  slight 
sclerotic  changes  in  the  lateral  columns,  atrophy  of  the  anterior  nerve  roots 
and  of  the  muscles  which  they  supply. 

Symptoms.  The  onset  of  the  disease  is  usually  sudden,  although  such 
prodromal  symptoms  as  slight  malaise  and  rise  of  temperature  are  sometimes 
observed.  The  sudden  onset  is  characterized  by  a  moderate  but  rapid  rise 
in  temperature — ioi°  to  102.5°  F.  (38.5°-39.2°  C),  rarely  as  high  as  105°  F. 
(40.5°  C.) — headache,  pains  in  the  back,  limbs  and  joints,  vomiting  and, 
perhaps,  stupor.  Slight  convnilsions  may  occur,  but  are  rare,  as  is  delirium 
or  coma.  The  paralysis  may  set  in  at  once  or  not  until  the  constitutional 
symptoms,  which  seldom  last  longer  than  two  or  three  days,  have  abated. 

This  involves  both  legs  equally  in  the  majority  of  patients,  next  in  frequency 
one  leg,  next  an  arm  and  a  leg.  Various  other  combinations  may  occur  but 
are  less  common  than  the  foregoing.  The  muscles  of  the  eye,  the  larynx 
and  those  of  respiration  are  unaffected  but  in  adults  the  facial  nerve  may  be 
involved.  The  paralysis  reaches  its  height  in  from  one  to  four  days  after  the 
invasion,  remains  stationary  for  from  two  to  six  weeks  and  then  gradually  im- 
proves; seldom  does  it  wholly  disappear.  It  usually  remains  in  a  certain  group 
of  muscles.  In  the  legs  the  extensor  muscles  are  most  commonly  involved, 
in  the  arm  the  deltoid.  The  affected  limb  atrophies,  the  atrophy  being  most 
marked  in  the  permanently  paralyzed  muscles.  The  nutrition  of  the  whole 
limb  suffers  and  its  growth  is  impaired,  the  skin  temperature  is  subnormal, 
the  cutaneous  sensibility  is  unaffected,  the  sphincters  of  the  bladder  and 
rectum  remain  normal;  the  reflexes  at  the  level  of  the  lesion  are  lost,  elsewhere 
they  are  vmchanged. 

The  reaction  of  degeneration  is  present,  faradic  irritability  being  lost  within 
a  week  or  two;  galvanic  irritability  persists  but  is  diminished. 

Various  deformities  result,  not  so  much  from  the  paralysis  as  from  the  unop- 


756  DISEASES    OF    THE    NERVOUS    SYSTEM. 

posed  action  of  the  healthy  muscles;  of  these  the  most  frequent  are  talipes 
equinus  and  talipes  varus  and  valgus.  The  lack  of  development  in  the  affected 
leg,  when  only  one  is  involved,  results  in  tilting  of  the  pelvis  and  spinal  curva- 
tures. 

The  patient's  general  health  remains  unaffected.  The  prognosis  as  to  life 
is  good  but  as  to  final  recovery  is  less  favorable.  The  use  of  the  faradic 
current  is  an  excellent  means  of  ascertaining  which  muscles  will  be  perman- 
ently affected.  After  two  weeks  the  muscles  in  which  faradic  irritability  persists 
will  recover  entirely.  After  three  months  the  muscles  in  which  it  has  returned 
will  recover  to  some  extent;  after  six  months  the  muscles  which  do  not  react 
will  remain  permanently  involved. 

Treatment.  During  the  acuity  of  the  disease  the  patient  should  be  kept 
in  bed,  at  the  onset  the  bowels  should  be  opened  by  fractional  doses  of  calomel 
followed  by  a  saline,  and  diaphoresis  should  be  induced  by  hot  mustard  baths 
or  the  hot  pack.  For  the  febrile  movement  tincture  of  aconite,  i  to  2  minims 
(0.065-0.130)  every  half  to  one  hour,  should  be  administered;  small  doses  of 
antipyrine  or  spiritus  aetheris  nitrosi,  ^  to  i  drachm  (2.0-4.0)  every  four  hours 
may  be  given.  The  administration  of  the  salicylates  and  of  ergot  has  been 
suggested,  the  former  particularly  in  patients  of  rheumatic  heredity,  but  it  is 
doubtful  if  they  or  any  other  drug  of  which  we  now  have  cognizance  can  influ- 
ence the  progress  of  the  lesion.  Counter -irritation  to  the  spine  by  means  of 
leeches,  dry  cups,  the  Paquelin  cautery,  mustard,  iodine  or  ice  bags  is  indicated, 
but  we  should  never  blister.  A  weak  mustard  paste  applied  at  intervals 
of  two  hours  and  sufficiently  long  to  redden  the  skin  is  as  effectual  as  anything. 
The  dry  cups  should  be  of  small  size  and  may  be  applied  to  the  skin  along  both 
sides  of  the  spinal  column.  The  child  should  be  encouraged  to  lie  on  its  stom- 
ach. In  the  chronic  stage,  drugs  are  of  little  value  but  nerve  and  general  tonics 
such  as  strychnine,  phosphorus,  iron,  arsenic  and  codliver  oil,  may  be  prescribed. 
At  the  end  of  two  or  three  weeks  the  use  of  electricity  may  be  cautiously  in- 
stituted, first  applying  the  electrodes  without  the  current  in  order  to  gain  the 
little  patient's  confidence.  The  galvanic  current  should  be  used  on  the  par- 
alyzed muscles,  the  faradic  on  those  unaffected.  Treatment  by  this  means 
may  be  given  two  or  three  times  a  week  for  the  first  month  or  so  and  for  the 
following  four  weeks,  daily,  each  limb  receiving  the  current  for  two  or  three  min- 
utes only;  after  an  intermission  of  two  or  three  weeks  another  month's  treat- 
ment should  be  started  and  so  on  at  intervals  until  a  year  has  elapsed.  After 
this  little  benefit  will  be  obtained  in  most  instances,  but  rarely  those  occur  in 
which  electricity  may  produce  good  results  even  later  in  the  disease.  It  must 
be  remembered  that  electricity  should  never  be  used  until  after  the  acute 
stage  has  passed,  and  then  never  for  a  sufficiently  long  time  to  tire  the  muscles. 
In  lessening  the  tendency  to  muscular  wasting,  systematic  massage  and  fric- 
tions, given  for  from  five  to  ten  minutes  daily  to  each  affected  limb,  are  even 


CHRONIC    ANTERIOR    POLIOMYELITIS.  757 

more  important  than  electricity.  The  patient  should  be  dressed  warmlv  and 
the  paralyzed  limb  especially,  should  be  kept  warm  and  to  this  end  may  be 
wrapped  in  cotton  at  night  or  surrounded  by  hot  water  bags.  An  excellent 
idea  is  to  allow  the  child  to  play  in  a  full  bath  of  salt  water  at  qS^-qq^  F. 
(36.9°-37.4°  C.)  for  a  half  hour  each  day. 

Exercise  and  life  in  the  open  air  should  be  advised  and  the  moderate  use 
of  light  gymnastic  apparatus  may,  in  proper  patients,  be  encouraged. 

Contractures  and  deformities  may  be  prevented  by  the  application  of  splints, 
braces  and  other  orthopaedic  appliances,  and  may  be  radically  corrected  often- 
times by  surgical  intervention,  tenotomies,  tendon  transplantations  and  the  like. 

CHRONIC  ANTERIOR  POLIOMYELITIS. 

Synonym.     Progressive  Spinal  Muscular  Atrophy. 

This  is  a  rare  disease,  is  most  often  seen  in  adult  males,  and,  while  its 
direct  causation  is  unknown,  exposure  to  cold  and  wet,  chronic  plumbism 
and  syphilis,  are  thought  to  contribute  to  its  incidence. 

Pathology.  The  morbid  anatomy  of  this  condition  consists  in  an  atrophy 
of  the  fibres  and  cells  of  the  anterior  cornua  of  the  cord.  There  is  no  acute 
inflammation,  but  merely  wasting  of  the  involved  nerve  tissues;  the  anterior 
lateral  columns  and  the  anterior  nerve  roots  are  also  affected  and  the  degen- 
erative process  extends  both  along  these  tracts  and  also  down  the  motor  nerve 
fibres  even  to  their  termination  in  the  muscles;  these  latter,  too,  are  involved 
in  turn,  their  striae  becoming  indistinct  and  fatty  degeneration  developing. 

Symptoms.  These  vary  with  the  portion  of  the  cord  diseased.  There  is 
usually  a  gradually  increasing  paralysis  of  the  extremities,  one  or  all,  followed 
by  atrophy  and  wasting;  the  reaction  of  degeneration  is  present,  the  bladder 
and  rectum  are  undisturbed;  the  reflexes  in  the  affected  muscles  are  lost; 
the  circulation  of  the  affected  limbs  is  poor  and  the  skin  cold.  There  is  no 
acute  stage  of  onset.  The  disease  steadily  progresses  with  greater  or  less 
rapidity  and  death  ensues  within  a  few  months  or  the  course  of  the  affection 
may  be  prolonged  for  a  year  or  two. 

Treatment.  This  is  practically  identical  with  that  of  the  chronic  stage  of 
acute  anterior  poliomyelitis.  Rest  is  essential,  massage  and  electricity  should 
be  employed,  a  course  of  mercury  and  potassium  should  be  instituted  and 
strychnine  and  arsenic  in  moderate  dosage  may  cause  some  improvement. 
Attention  should  be  given  to  the  general  hygiene  of  the  patient  in  the  way  of 
nourishing  food,  plenty  of  fresh  air,  etc. 

LATERAL  SCLEROSIS. 

Synonyms.  Spastic  Spinal  Paralysis;  Spastic  Paraplegia;  Spasmodic 
Tabes  Dorsalis. 


758  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Definition.  A  chronic  sclerosing  inflammation  of  the  lateral  pyramidal 
tracts  of  the  spinal  cord. 

iEtiology.  This  is  a  disease  of  adult  life,  although  it  has  been  observed  in 
children;  heredity  seems  to  exert  an  influence  in  some  cases.  The  condition 
■  seems  sometimes  to  occur  as  a  result  of  syphilis,  trauma,  exposure,  excessive 
muscular  exertion,  chronic  plumbism  and  the  infectious  diseases.  The 
so-called  Little's  disease  is  akin  to  lateral  sclerosis,  but  is  a  congenital  affection 
and  the  result  of  a  lack  of  development  of  the  lateral  tracts  or  due  to  prema- 
ture or  instrumental  delivery. 

Pathology.  The  sclerotic  change  in  the  lateral  pyramidal  tracts  usually 
begins  in  the  lumbar  cord  and  involves  the  crossed  pyramidal  tracts  as  well. 
The  degeneration  extends  upward  and  the  myelin  is  gradually  replaced  by 
connective  tissue.  Other  lesions  such  as  myelitis,  meningomyelitis  and 
multiple  sclerosis  often  co-exist  and,  when  the  process  reaches  the  cervical 
cord,  the  anterior  median  columns  may  be  affected. 

Symptoms.  The  patient's  attention  is  first  called  to  the  existence  of  this 
disease  by  a  feeling  of  fatigue  in  the  legs,  this  progressively  increases  until 
walking  becomes  difficult  owing  to  the  increased  spasticity  and  paralysis. 
The  gait  is  characteristically  "  spastic, "  that  is,  the  toes  drag,  the  knees  are  but 
little  flexed  and  overlap  one  another,  the  feet  are  hardly  lifted  and  the  motion 
is  stiff.  Contraction  of  the  muscles  of  the  calf  may  compel  the  patient  to 
walk  on  his  toes.  Motor  paresis  is  a  characteristic  symptom  but  at  times  is 
absent,  yet  the  spastic  condition  is  sufficient  to  disorder  the  gait,  even  though 
the  patient  may  be  able  to  walk  considerable  distances.  In  marked  degrees 
of  paresis  the  muscles  are  firm  and  tense  and  the  legs  are  held  permanently 
extended,  the  feet  being  in  a  position  of  plantar  flexion.  Sudden  attempts 
to  flex  the  knees  or  the  feet  upon  the  legs  are  resisted  but,  if  force  is  exerted 
gradually,  the  effort  will  be  successful.  The  patellar  reflex  is  markedly 
exaggerated,  ankle  clonus  and  the  Babinski  reflex  (upturning  of  the  toes, 
especially  the  great,  when  the  sole  is  stroked)  are  present.  The  reaction  of 
degeneration  is  absent,  the  bladder  and  rectal  functions  are  normal,  there 
are  no  sensory  disorders  nor  does  atrophy  appear  until  late  in  the  disease. 
The  disease  progresses  but  slowly,  the  patient,  in  the  later  stages  being  unable 
to  walk  or  stand.  The  muscles  of  the  arms  are  seldom  affected,  but  when 
this  does  occur,  the  extensors  are  first  and  chiefly  involved,  the  paresis  and 
exaggeration  of  the  tendon  reflexes  being  analogous  to  that  found  in  the 
lower  extremities. 

Hysteria  may  exactly  reproduce  the  symptoms  above  described  (hysteric 
spastic  paraplegia)  but  the  differential  diagnosis,  while  not  easy,  may  be  made 
upon  finding  other  hysterical  manifestations. 

The  prognosis.  The  progress  of  this  disease  is  slow  and  prolonged  and  re- 
covery is  not  to  be  expected.   The  general  health  and  the  mind  are  not  disturbed. 


AMYOTROPHIC    LATERAL    SCLEROSIS.  759 

Treatment.  If  syphilis  is  suspected  the  patient  should  be  put  upon  mer- 
curial inunctions  and  potassium  iodide;  the  spastic  condition  of  the  limbs 
may  be  lessened  in  certain  cases  by  conium  extract,  gr.  ^  to  i  (0.032-0.065),  the 
bromides  or  hydrated  chloral;  the  latter  drug,  however,  should  be  given  with 
the  greatest  caution  lest  the  habit  become  established.  Galvanism  and  farad- 
ism  may  be  employed  and  while  they  are  likely  to  accomplish  little  in  the 
ordinary  type  of  the  disease,  in  hysterical  spastic  paraplegia  they  are  very 
useful  on  account  of  the  impression  made  upon  the  patient.  Massage  and 
passive  movements,  when  not  too  vigorous,  may  lessen  the  spasticity  and  the 
patient  should  be  encouraged  to  do  a  moderate  amount  of  walking  so  as  to 
keep  the  legs  as  limber  as  possible.  Warm  baths  lasting  from  twenty  to  forty 
minutes  at  a  temperature  of  92°-98°  F.  (33.3°-36.7°  C),  during  which  passive 
movements  are  practiced,  are  often  of  benefit. 

Braces  and  other  appliances  are  useful  in  special  instances  and  tenotomies 
may  become  necessary  in  order  to  straighten  the  limbs. 

AMYOTROPHIC  LATERAL  SCLEROSIS. 

Synonym.     Charcot's  Disease. 

Definition.  A  chronic  disease  characterized  by  degeneration  of  the  lateral 
columns  of  the  spinal  cord,  associated  with  atrophy  of  the  motor  cells  in 
the  anterior  horns  and  medulla,  and  a  consequent  progressive  atrophy  of  the 
muscles. 

.Etiology.  This  disease  is  most  frequently  met  in  males  from  twenty- 
five  to  fifty  years  of  age.  Its  actual  cause  is  unknown  but  it  is  probably 
the  result  of  an  imperfectly  developed  nervous  system.  Contributory  causes 
are  said  to  be  exposure,  over-exertion,  the  abuse  of  alcohol,  chronic  metallic 
poisoning  and  injury. 

Pathology.  The  essential  lesions  are  a  sclerotic  degeneration  of  the  crossed 
pyramidal  tracts  of  the  lateral  columns,  a  like  change  in  the  anterior  median 
columns  of  the  spinal  cord  and  an  atrophy  of  the  motor  cells  in  the  anterior 
horns;  the  changes  are  most  frequently  found  in  the  cervical  cord  but  may, 
in  old  cases,  involve  the  lumbar  region  as  well.  The  sclerosis  in  the  motor 
columns  may  extend  to  the  motor  cells  of  the  cerebrum,  through  the  medulla, 
pons,  crura  cerebri,  capsule  and  corona  radiata,  involving  on  its  way  the 
cranial  nerve  nuclei  in  the  floor  of  the  fourth  ventricle.  The  sclerosis  consists, 
first,  of  a  wasting  of  the  normal  nervous  substance  and  secondly  in  a  re- 
placement by  connective  tissue. 

Symptoms.  These  depend  upon  the  portion  of  the  nervous  system  first 
affected  by  the  disease.  When  the  disorder  begins  in  the  cervical  cord  and 
.the  anterior  horn  cells,  the  muscles  of  the  arms  become  stiff  and  their  reflex 
irritability  is  exaggerated,  this  is  accompanied  by  a  certain  amount  of  paresis, 


760  DISEASES    OF    THE    NERVOUS    SYSTEM. 

followed  by  atrophy  of  the  muscles  of  the  hands,  the  extensors  being  Involved 
before  the  flexors;  as  the  paresis  extends  further  up  the  arm  the  atrophy  also 
progresses  and  is  especially  marked  in  the  deltoid.  Fibrillary  contractions 
appear  early,  and  the  fingers  are  often  held  in  a  position  of  mid-flexion,  and 
the  muscles  being  rigid,  it  may  be  difficult  for  the  observer  to  straighten  them. 

The  symptoms  later  involve  the  legs,  but  in  rare  cases  the  lower  limbs  may 
be  first  affected.  The  symptoms  referable  to  these  extremities  are  fatigue, 
a  stiff  gait,  difficulty  in  rising  from  a  sitting  posture,  tremor,  paresis  and  atrophy ; 
one  limb,  either  upper  or  lower,  may  be  much  more  seriously  affected  than 
the  others. 

The  electric  excitability  of  the  muscles  is  diminished  and  the  reaction  of 
degeneration  may  be  present.  The  knee  jerk  is  exaggerated,  and  ankle 
clonus  and  the  Babinski  symptom  are  frequently  to  be  obtained.  Sensation 
remains  unaffected  and  there  is  no  disturbance  of  bladder  or  rectum  except 
that,  in  lumbar  involvement,  there  may  be  nocturnal  incontinence  of  urine. 
The  sexual  power  may  be  lost. 

Late  in  the  course  of  the  disease  bulbar  symptoms  may  appear,  speech 
becoming  disordered,  swallowing  difficult  and  there  may  be  dripping  of  the 
saliva.  Atrophy  of  the  tongue  and  lips  may  occur  and,  the  patient  being 
unable  to  properly  masticate  and  swallow  his  food,  nutrition  becomes  impaired. 
The  pupils  may  be  unequal  and  while  there  is  usually  no  loss  of  mental  power, 
dementia  of  mild  type  may  develop. 

The  prognosis  is  not  favorable,  although  the  patient's  life  may  be  pro- 
longed and  much  may  be  done  to  make  him  comfortable.  Death  occurs  from 
exhaustion,  intercurrent  disease  and  not  seldom  from  foreign  body  pneu- 
monia due  to  the  disturbance  of  swallowing. 

Treatment  should  be  carried  out  along  the  same  lines  as  in  lateral  sclerosis. 
Feeding  by  means  of  the  stomach  or  nasal  tube  may  be  necessary  if  advanced 
bulbar  symptoms  are  present. 

LOCOMOTOR  ATAXIA. 

Synonyms.  Tabes  Dorsalis;  Posterior  Spinal  Sclerosis;  Duchenne's 
Disease. 

Definition.  A  chronic  disease  of  the  posterior  columns  and  nerve  roots 
of  the  spinal  cord,  characterized  by  sensory  and  trophic  symptoms  and  dis- 
tiubances  of  coordination. 

.Etiology.  This  affection  is  most  often  seen  in  middle  life  but  may  occur 
as  early  as  the  tenth  or  as  late  as  the  sixty-fifth  year.  Heredity  is  a  negligible 
factor  save  as  regards  inherited  syphilis.  Exposure,  excessive  exertion,  both 
physical  and  mental,  and  sexual  excesses  have  been  considered  to  have  a  place 
in  the  causation  of  locomotor  ataxia,  but  the  most  important  factor  in  its 


LOCOMOTOR    ATAXIA.  76 1 

aetiology  is  syphilitic  disease.  Various  observers  state  that  syphilis  is  an 
element  in  the  causation  of  from  60  to  90  percent,  of  all  cases.  It  seldom  occurs 
within  five  years  of  the  primary  lesion  and  often  not  until  a  much  later  period; 
it  seems  to  appear  more  frequently  in  individuals  whose  secondary  period 
has  been  characterized  by  mild  symptoms.  The  disease  seems  to  be  rather  a 
result  of  luetic  infection  than  a  syphilitic  affection  of  the  spinal  cord. 

Pathology.  On  microscopical  inspection  the  cord  is  found  to  be  dimin- 
ished in  calibre  and  the  posterior  columns  may  be  noticeable  as  a  grayish  band; 
the  pia  mater  is  usually  thickened  and  less  transparent  than  normal  and  its 
vessels  are  sclerosed.  Section  of  the  cord  reveals  an  atrophy  of  the  posterior 
columns  and  of  the  posterior  nerve  roots.  Microscopically  the  posterior 
columns  are  seen  to  be  the  seat  of  sclerosis,  their  normal  structure  having  been 
replaced  by  connective  tissue.  The  same  condition  obtains  in  the  posterior 
nerve  roots,  a  degenerative  neuritis  may  involve  the  sensory  fibres  of  the 
larger  nerve  trunks  and  the  finer  sensory  nerves  may  contain  degenerated 
fibres.  The  process  usually  begins  in  the  lateral  zone  of  the  column  of  Bur- 
dach  and  in  the  column  of  Lissauer  at  about  the  level  of  the  second  and  third 
lumbar  segments,  thence  it  spreads  through  the  middle  zone  of  Burdach's 
column  to  the  column  of  Goll  and  finally  to  the  posterior  zone  of  the  column 
of  Burdach.  The  disease  at  the  same  time  is  extending  upward,  and  al- 
though the  process  may  take  years,  eventually  the  entire  area  of  the  posterior 
columns  is  involved,  together  with  the  posterior  nerve  roots,  the  posterior 
horns  of  the  cord  and  the  medullated  fibres  of  Clarke's  column.  Ultimately 
there  may  be  changes  in  the  brain  itself. 

Symptoms.  These  are  best  classified  according  to  the  time  of  their  inci- 
dence, the  disease  developing  in  three  more  or  less  distinct  stages. 

a.  The  Stage  of  Pain.  Most  of  the  symptoms  of  this  stage  are  sensory. 
There  are  various  paraesthesiae,  such  as  numbness  and  tingling  of  the  feet, 
a  sensation  as  if  cotton  were  being  trodden  upon,  sensations  of  burning  or  of 
cold  and  pruritus  over  various  areas,  notably  the  scrotum  and  at  the  anus. 
Pain  is  an  early  and  prominent  symptom  and  may  continue  throughout  the 
course  of  the  disease.  It  usually  begins  in  the  thighs  or  lower  legs  and  extends 
as  the  disease  progresses.  In  certain  cases  it  may  be  slight  or  wholly  absent, 
particularly  when  the  onset  of  the  disease  is  characterized  by  optic  nerve 
atrophy.  The  pain  is  sharp,  lightning-like,  lancinating,  cutting  or  boring  in 
character,  often  beginning  on  the  outside  and  anterior  surface  of  the  thigh 
and  later  extending  to  the  feet;  it  usually  appears  in  repeated  paroxysms 
lasting  from  a  second  or  two  to  half  a  minute,  or  it  may  occur  in  attacks  lasting, 
without  remission,  for  hours  or  days.  There  is  no  tenderness.  There  may 
be  aching  pain  in  the  back  and  loins,  or  girdle  sensations  about  the  legs, 
ascending  to  the  body  as  the  disease  involves  higher  levels  of  the  cord.  The 
patellar  reflex  is  lost  (Westphal's  symptom);  spinal  myosis  (contracted  pupil) 


762  DISEASES    OF    THE    NERVOUS    SYSTEM. 

may  be  present;  the  pupil  reacts  in  accommodation  but  not  to  light  (Argyll- 
Robertson  pupil);  intermittent  oscellation  of  the  iris  due  to  the  influence  of 
light  may  be  seen  (Gowers'  sign);  the  bladder  control  may  be  partly  lost;  com- 
plete incontinence  may  finally  result.     Sexual  impotence  is  not  rare. 

b.  The  Stage  of  Ataxia.  The  symptoms  of  the  first  stage  persist  and  in 
addition  disturbances  of  sensation  appear.  Pain  sense  is  lessened  and  delayed, 
a  pin  prick  may  not  be  felt  until  after  a  perceptible  interval,  or  hyperalgesiae  may 
be  present,  pain  being  caused  by  even  the  touch  of  a  finger.  Anaesthesia  of  the 
popliteal  space  may  occur  (Bechterew's  sign).  The  temperature  sense  is  dis- 
turbed, the  patient  becoming  very  susceptible  to  cold,  while  heat  is  felt  less 
than  normal;  ultimately  the  limbs  become  vi^holly  ana?sthetic. 

The  muscular  sense  is  impaired,  the  position  of  the  body  in  space  is  not 
correctly  perceived  and  the  patient  consequently  v^ralks  unsteadily,  especially 
in  the  dark  when  sight  is  unable  to  assist  the  muscular  sense,  and  is  unable  to 
accurately  touch  objects  when  his  eyes  are  shut;  for  instance  he  has  difficulty  in 
placing  his  finger  upon  the  tip  of  his  nose  when  blindfolded;  finer  move- 
ments of  the  hands  and  fingers  are  performed  inaccurately;  difficulty  is  experi- 
enced in  picking  up  small  objects,  in  buttoning  the  clothes  and  in  writing.  The 
gait  is  characteristically  ataxic,  the  patient  walks  with  the  legs  widely  separated 
and  the  body  poorly  balanced,  he  lifts  the  feet  too  high  and  plants  them  too 
forcibly,  bringing  down  the  heel  with  a  stamp;  his  steps  are  irregular  in  length, 
he  staggers  and  cannot  walk  in  a  straight  line,  especially  if  the  eyes  are  closed. 
When  the  feet  are  placed  closely  together  and  the  patient  stands  with  eyes  closed, 
he  reels  and  may  fall  (Romberg's  symptom).  There  is  diminished  tonicity 
of  the  hip  muscles  (Frankel's  sign). 

Various  ophthalmic  disturbances  may  occur,  such  as  optic  nerve  atrophy, 
with  resulting  blindness,  ocular  nerve  paralyses  with  consequent  ptosis  and 
strabismus,  convergent  with  contracted  pupil  when  the  sixth  nerve  is  affected, 
divergent  with  dilated  pupil  with  involvement  of  the  third;  the  pupil  may  be 
oval  or  irregular  (Berger's  sign) ;  unilateral  deafness,  due  to  auditory  nerve 
atrophy,  may  develop.     The  other  cranial  nerves  may  be  affected. 

During  this  stage  the  so-called  "crises"  may  appear.  These  are  probably 
due  to  a  complicating  pneumogastric  neuritis  and  are  of  various  types.  The 
gastric  crisis  is  the  most  frequent  and  is  characterized  by  sudden  severe 
pain  and  vomiting  which  may  persist  for  several  hours  or  even  a  day  or  two; 
intestinal  and  rectal  crises  are  associated  with  pain,  diarrhceal  tenesmus  or  a  sen- 
sation of  a  foreign  body  in  the  rectum;  laryngeal  crises  are  characterized  by  sud- 
den cough,  stridor,  glottic  spasm  and  dyspnoea;  cardiac  crises  resembling  attacks 
of  angina  pectoris,  and  vaginal  crises,  characterized  by  pain  and  copious 
mucous  discharge,  have  also  been  observed.  Trophic  disorders,  evidenced 
by  the  so-called  "  Charcot  joint,"  an  affection  probably  having  its  origin  in  a 
traumatism  which  is  disregarded  by  the  patient  because  of  disturbance  of  his 


LOCOMOTOR    ATAXIA.  763 

pain  sense,  and  which  is  characterized  by  entire  absence  of  pain,  great  sweUing 
and  copious  effusion,  occur.  The  knee  is  most  frequently  affected  but  the 
condition  may  involve  the  ankle,  elbow  or  wrist.  The  ligaments,  cartilage 
and  bone  are  gradually  destroyed  and  spontaneous  fracture  or  dislocation 
may  result.  Perforating  ulcer  of  the  foot,  resulting  from  a  neglected  injury 
often  of  slight  character,  may  occur.  Other  trophic  disturbances  are  rar- 
efaction of  the  bones,  with  resulting  fractures,  irregular  atrophy  of  muscles 
and  various  skin  eruptions. 

c.  The  Stage  oj  Paralysis.  The  ataxia  gradually  increases  until  the  patient 
becomes  helpless;  the  bladder  and  rectum  are  incontinent  and  bed-sores  are 
apt  to  develop;  cystitis  with  consequent  pyelitis  may  result  from  the  use  of 
the  catheter;  the  patient  is  confined  to  his  bed,  even  though  his  general  nutri- 
tion remains  good. 

The  prognosis.  The  course  of  the  disease  is  chronic  and  may  extend  over 
twenty  or  thirty  years.  The  first  stage  lasts  from  a  few  months  to  fifteen 
or  twenty  years,  the  second  may  develop  slowly  or  rapidly  and  the  third  stage 
is  soon  terminated  by  death.  The  prognosis  should  always  be  guarded;  it  is 
believed  that  recovery  has  never  taken  place  but  the  progress  of  the  disease 
may  be  stopped  or  at  least  delayed.  The  thoroughness  with  which  syphilitic 
disease  of  late  years  has  been  treated  seems  to  have  borne  fruit  in  that  mild 
types  of  locomotor  ataxia  are  becoming  more  frequent. 

Treatment,  In  all  cases  in  which  there  is  suspicion  of  syphilis,  appropriate 
treatment  in  the  form  of  mercurial  inunctions — one  drachm  (4.0)  of  the  oint- 
ment should  be  thoroughly  rubbed  into  the  inner  aspect  of  the  thigh  or  arm 
daily  until  the  gums  become  sore,  when  mercury  bichloride  may  be  substi- 
tuted— gr.  ^  (0.003)  three  times  a  day — and  the  internal  administration 
of  potassium  iodide  in  ascending  doses  should  be  begun.  The  dosage  of  the 
latter  must  be  governed  by  its  effect,  as  much  as  possible  being  given  without 
inducing  iodism;  after  the  limit  is  reached  the  doses  should  be  diminished  by 
about  one-half  and  continued  for  several  months.  If  the  primary  specific 
lesion  is  not  of  recent  date  certain  authorities  are  inclined  to  omit  the  mer- 
cury and  depend  chiefly  upon  the  potassium  iodide,  others  consider  the  use 
of  the  former  drug  to  be  contraindicated  in  cases  with  optic  nerve  atrophy 
on  the  ground  that  it  may  hasten  the  process.  Mercury  biniodide  may  at 
times  be  employed  with  good  effect  in  doses  of  gr.  -gig-  (0.003)  three  times 
a  day  and  a  change  of  the  potassium  iodide  to  the  strontium  salt  (gr.  xx  to 
XXX — 1.33-2.0 — three  times  a  day)  or  to  the  syrup  of  hydriodic  acid,  i 
drachm  (4.0)  at  the  same  intervals,  may  prove  beneficial. 

The  disadvantages  of  antisyphilitic  treatment  are  that  it  may  cause  diges- 
tive disturbances  which  result  in  an  impairment  of  nutrition  and  that  excessive 
administration  of  mercury  may  produce  distressing  neurasthenic  conditions. 
When  after  thorough  trial  it  is  certain  that  no  benefit  from  this  form  of  treat- 


764  DISEASES    or    THE    NERVOUS    SYSTEM. 

ment  is  to  be  expected  it  should  be  stopped;  if  it  acts  favorably'  it  should 
be  continued,  the  mercury  being  alternated  with  the  iodide,  a  period  of  tliree 
months  being  devoted  to  each,  or  the  tviro  should  be  given  simultaneously  for 
three  months,  omitted  for  a  like  period,  then  repeated  and  so  forth. 

Various  other  drugs  have  been  from  time  to  time  exploited  as  efficacious 
in  locomotor  ataxia;  of  these  those  most  likely  to  be  affective  are  arsenic,  in 
the  form  of  Fovsrler's  solution  n^  v(o.33),  arsenic  trioxide,  gr.  -gL  to  -^-^  (0.002- 
0.003)  or  sodium  arsenate,  gr.  Jq  to  y^  (0.002-0.006)  three  times  a  day, 
aluminum  chloride  gr.  iii  to  x  (0.2-0.66)  tliree  times  a  day,  strychnine,  gr. 
3V  (0.002)  or  less  thrice  or  four  times  daily,  calcium  glycerophosphate,  gr. 
iii  to  V  (0.2-0.33)  and  calcium  hypophosphite,  gr.  x  to  xxx  (0.66-2.0).  Silver 
has  been  advocated  but  it,  barium,  gold,  ergot  and  physostigma  are  prob- 
ably of  no  effect  and  are  little  used. 

Much  can  be  done  in  this  disease  toward  mitigating  the  symptoms;  the 
pains  may  be  controlled  by  the  coal  tar  analgesics,  antipyrine,  acetanilide, 
acetphenetidine,  salophen,  salipyrine,  or  aspirin  in  the  usual  doses;  this  symptom 
at  times  may  yield  to  a  drachm  (4.0)  of  sodium  bicarbonate;  codeine,  gr. 
J  to  ^  (0.016-0.032)  may  prove  effectual,  as  also  may  extract  of  cannabis 
indica  (gr.  ^  to  ^  (0.016-0.032)  or  cocaine,  hypodermatically,  gr.  \io\  (o.oii- 
0.016).  The  Paquelin  cautery  applied  once  or  twice  a  week  is  a  useful  agent 
in  the  severe  pains;  cups,  leeches  and  blisters  may  also  be  employed  with 
good  effect.  Morphine  in  the  severe  pain  may  become  necessary,  it  should 
be  given  under  the  skin  and  only  after  all  other  means  have  failed,  on  account 
of  the  danger  of  establishing  the  habit.  The  insomnia  may  be  relieved  by 
the  bromides,  veronal,  gr.  x  to  xv  (0.66-1.0),  sulphonethylmethane  in  the 
same  doses  or  sulphonmethane,  gr.  xx  (1.33).  Hydrated  chloral  may  in  ex- 
treme instances  be  combined  with  the  bromides. 

The  bladder  disturbances  may  be  rendered  less  distressing  by  the  adminis- 
tration of  hyoscyamus  combined  with  the  balsams,  and  small  doses  of  strych- 
nine, gr.  y-^  (0.0006),  may  be  given  if  sexual  weakness  is  present.  Neu- 
ralgic pains  in  the  rectum  often  disappear  after  an  enema  and  a  thorough 
evacuation.  Suppositories  containing  iodoform,  codeine  and  belladonna 
may  be  efficacious. 

In  the  crises  a  hypodermatic  injection  of  morphine  is  often  the  only  thera- 
peutic measure  which  will  relieve  the  patient. 

From  the  beginning  of  the  treatment  the  physician  should  insist  upon  the 
importance  of  systematic  rest.  It  may  be  advisable  to  put  the  patient  to  bed 
for  a  number  of  weeks.  If  so  drastic  a  measure  is  not  necessary  a  regular 
life  should  be  prescribed,  with  moderate  exercise  and  avoidance  of  all  mental 
and  physical  labor.  The  excessive  use  of  alcohol  and  tobacco  must  be  for- 
bidden as  well  as  more  than  moderate  venery.  Institution  treatment  for  a 
number  of  months  each  year  is  often  of  great  benefit. 


LOCOMOTOR   ATAXIA.  765 

Electricity  is  useful  for  its  tonic  effect  upon  the  muscular  and  nervous 
systems  and  if  employed  perseveringly  may  benefit  the  lesion  itself.  Galvan- 
ism (15  to  30  milliamperes)  may  be  administered  by  applying  the  anode 
to  the  side  of  the  neck  and  moving  the  kathode  up  and  down  the  spine  and 
limbs.  Both  the  constant  and  the  interrupted  currents  may  be  employed 
in  this  manner;  the  former  may  be  effective  in  the  pains  and  the  latter  is 
indicated  in  vesical  weakness. 

Hydrotherapeutic  measures  are  often  beneficial  but  have  disadvantages, 
in  that  the  patient  often  fails  to  react  after  the  cool  bath  and  the  warm  bath 
is  likely  to  prove  enervating.  Oftentimes,  however,  a  daily  lukewarm  bath 
lasting  for  fifteen  or  twenty  minutes,  after  which  a  cool  douche  is  applied 
to  the  spine  and  the  patient  is  vigorously  rubbed,  is  an  excellent  procedure. 
Wet  compresses  to  the  limbs  are  often  useful  to  ease  the  pains  and  douches 
neither  hot  nor  cold  often  affect  the  patient  favorably.  Spa  treatment  with 
systematic  bathing  may  confer  benefit  but  probably  rather  from  the  regular 
life  led  at  such  resorts  than  from  any  effect  of  the  bathing  itself. 

Treatment  by  suspension  was  much  advocated  a  number  of  years  ago.  The 
patient  was  harnessed  about  the  neck  and  shoulders  with  a  specially  constructed 
apparatus  and  was  by  this  means  lifted  from  the  floor.  This  was  done  for  a 
minute  or  two,  two  or  three  times  a  week  for  eight  or  ten  weeks,  and  after  an 
interval  of  several  months,  the  procedure  was  repeated.  This  method  seemed 
to  benefit  some  cases  but  is  little  employed  at  present.  It  is  useless  in  the 
stage  of  paralysis.  Treatment  by  means  of  education  of  the  muscular  sense 
(the  method  of  Frasnkel)  is  often  valuable.  This  consists  of  systematic  exer- 
cises calculated  to  educate  certain  nerve  fibres  of  the  cord  so  that  they  may 
be  able  to  perform  the  function  of  those  which  have  been  destroyed.  The 
idea  is  to  train  the  patient  in  certain  motions  requiring  coordination.  The 
exercises  may  be  greatly  varied,  among  those  applicable  are  to  require  the 
patient  to  walk  a  straight  line  drawn  upon  the  floor,  to  draw  sets  of  parallel 
lines  with  one  hand,  then  with  the  other,  etc.  For  an  extended  list  the  reader 
is  referred  to  Dana's  Textbook  of  Nervous  Diseases.  This  method,  while 
it  does  not  influence  the  lesion,  often  enables  the  patient  to  use  his  limbs  to 
better  advantage  and  is  particularly  effective  in  patients  in  the  latter  part 
of  the  first  or  early  in  the  second  stage. 

There  is  no  special  diet  to  be  prescribed.  The  patient  should  eat  regularly 
a  sufficient  quantity  of  nourishing  and  easily  digestible  and  assimilible  food. 
Fats,  starches  and  proteids  are  all  allowable. 

Patients  should  be  encouraged  to  use  every  means  to  combat  their  disease 
and  to  carry  out  a  systematic  treatment.  Those  who  have  the  courage  and 
energy  to  do  this  will,  after  a  time,  reap  the  benefit  of  their  perseverance 
and  reach  a  condition  in  which  they  may  lead  comparatively  comfortable 
lives. 


766  DISEASES   OF    THE    NERVOUS    SYSTEM. 

FRIEDREICH'S  ATAXIA. 

Synonyms.  Hereditary  Ataxia;  Hereditary  Ataxic  Paraplegia;  Family 
Ataxic  Paraplegia;  Friedreich's  Disease. 

Dej&nition.  A  chronic  disease  of  the  spinal  cord,  occurring  hereditarily 
and  characterized  by  ataxia  and  paraplegia. 

.etiology.  The  direct  causative  factor  of  this  disease  is  unknown.  It 
seems  to  occur  rather  more  frequently  in  males  than  in  females;  it  may  occur 
in  infancy  but  the  greater  number  of  cases  develop  between  the  ages  of 
three  and  fifteen  years.  It  very  rarely  appears  after  the  age  of  twenty-five. 
The  condition  is  probably  due  to  lack  of,  or  to  poor  development  of  certain 
tracts  in  the  spinal  cord.  It  sometimes  follows  an  acute  infectious  disease, 
and  alcoholism,  syphilis  and  the  neurotic  tendency  in  the  parents,  seem  in 
some  measure  to  be  predisposing  factors. 

Pathology.  The  lesions  of  Friedreich's  disease  are  found  in  the  posterior 
and  lateral  columns  of  the  cord  and  consist  of  a  degeneration  involving  these 
tracts  and  at  times  also  the  columns  of  Clarke  and  Gowers.  On  examination 
the  cord  is  found  to  be  smaller  than  normal  and  the  pia,  over  the  posterior 
columns  especially,  is  thickened.  The  normal  tissue  is  seen  to  be  degenerated 
and  to  some  extent  replaced  by  neuroglia,  the  cells  in  the  anterior  and  poste- 
rior cornua  are  atrophied  and  this  change  affects  also  the  anterior  and  posterior 
nerve  roots. 

Symptoms.  These  are,  as  would  be  expected,  a  combination  of  those  of 
lateral  sclerosis  and  locomotor  ataxia — paraplegia  with  ataxia.  Pains  at  the 
onset  are  infrequent,  the  first  symptom  noticed  being  a  gradual  loss  of  coor- 
dination first  affecting  the  legs.  The  patient  totters  and  with  diflficulty 
maintains  his  equilibrium,  he  sways  in  walking  and  may  fall.  Romberg's 
symptom  may  be  present;  the  patellar  reflex  is  usually  absent,  but  rarely  may 
be  exaggerated.  The  ataxia  of  the  arms  is  characterized  by  choreic  and 
irregular  movements;  in  grasping  objects  there  seems  to  be  an  excess  of  move- 
ment. As  the  disease  progresses  the  jerky  movements  involve  the  head  and 
there  may  be  accompanying  tremor,  nystagmus  is  present  when  the  eyeballs 
are  moved  but  is  absent  when  they  are  at  rest.  The  pupils  are  usually  normal 
and  optic  atrophy  is  very  rare.  Scanning  speech  with  elision  of  syllables 
may  occur  late  in  the  disease. 

The  paresis  appears  later  than  the  ataxia  and  chiefly  affects  the  legs;  the 
power  of  the  muscles,  the  flexors  more  than  the  extensors,  is  impaired  and 
consequent  talipes  may  occur;  if  the  muscles  of  the  body  are  affected,  curva- 
tures of  the  spine  result.  The  nutrition  of  the  muscles  is  little  if  at  all 
impaired. 

There  is  a  lack  of  sensory  symptoms  except,  at  times,  cramp-like  muscular 
contractions  in  the  earlier  stages  which  may  cause  discomfort.     Rarely  there 


BULBAR    PARALYSIS.  767 

are  disorders  of  the  pain  and  temperature  senses  and  sensation  may  be  slightly 
delayed. 

The  mind  is  not  materially  affected,  but  children  in  whom  the  disease 
appears  early  in  life,  seldom  attain  normal  development  in  this  regard. 

The  prognosis  as  regards  recovery  is  utterly  unfavorable  but  the  progress 
of  the  affection  is  slow  and  may  be  interrupted  by  periods  of  remission;  patients 
who  are  attacked  in  the  earlier  years  of  life  seldom  survive  to  attain  maturity. 

Treatment  is  of  little  avail.  With  regard  to  prophylaxis,  we  should,  when 
the  disease  has  occurred  in  one  member  of  a  family,  endeavor  to  impress  upon 
the  parents  the  necessity  of  especial  care  in  the  feeding  and  general  manage- 
ment of  the  others.  Breast-feeding  should  be  insisted  upon,  all  infections 
and  traumatisms  guarded  against  and  excessive  physical  exertion  avoided. 
Patients  affected  with  the  disease  should  receive  nourishing  and  easily-digest- 
ible food  and  live  in  as  hygienic  a  manner  as  possible.  Nerve  tonics  may 
be  employed  and  may  be  of  some  benefit,  suspension  may  be  tried  and  has 
seemed  to  act  favorably  in  certain  cases.  The  therapeutic  means  applicable 
to  locomotor  ataxia  are  worthy  of  trial.  Tendency  to  contractures  and  defor- 
mity may  be  combated  by  orthopaedic  methods  and  apparatus. 

HEREDITARY  CEREBELLAR  ATAXIA. 

This  is  a  condition  characterized  by  all  of  the  symptoms  of  Friedreich's 
disease  with  the  exceptions  that  in  the  former  affection  there  are  various  ocu- 
lar disturbances  such  as  atrophy  and  paralyses,  together  with  an  increased 
patellar  reflex.  The  condition  usually  appears  after  the  age  of  twenty 
and  is  the  result  of  congenital  defect  in  or  incomplete  development  of  the 
cerebellum. 

Recent  research  seems  to  tend  to  draw  cerebellar  ataxia  and  ataxic  para- 
plegia more  closely  together  as  regards  lesions  and  symptoms  and  it  is  quite 
possible  that  they  will  come  to  be  regarded  as  types  of  the  same  disease. 

Like  Friedreich's  ataxia,  this  disease  is  progressive  and  with  regard  to 
treatment  one  can  hardly  do  more  than  maintain  the  patient's  nutrition. 
Otherwise  the  affection  may  be  managed  in  a  manner  identical  with  that 
described  under  the  treatment  of  the  former  condition. 

BULBAR  PARALYSIS. 

Synonym.     Glosso-labio-laryngeal  Paralysis. 

Definitioji.     A  progressive  paralysis  involving  the  tongue,  lips,  throat  and 
larynx  and  in  advanced  instances  the  muscles  of  the  lower  part  of  the  face. 
.Etiology.     This  disease  occurs  most  frequently  in  middle  age.     Syphilis, 


76S  DISEASES    OF    THE    NERVOUS    SYSTEM. 

exposure,  and  mental  and  physical  over-work  have  been  considered  possible 
causative  factors  but  the  direct  aetiology  of  the  condition  is  unknown. 

Pathology.  The  morbid  change  which  characterizes  this  disease  consists 
in  a  degeneration  of  the  nuclei  of  origin  of  the  motor  nerves  which  supply  the 
lips,  tongue,  throat  and  larynx.  In  certain  cases  the  lesion  spreads  to  the 
cranial  nerve  nuclei  on  the  floor  of  the  fourth  ventricle  of  the  medulla  in- 
volving the  vagus,  the  fifth  in  its  motor  fibres,  the  seventh,  the  ninth,  the 
twelfth,  and  exceptionally  the  abducens  and  motor-oculi.  The  degenerative 
change  is  characterized  by  a  wasting  of  the  normal  nerve  tissue  and  a  re- 
placement of  it  by  neuroglia,  with  connective  tissue  increase  in  the  walls  of 
the  blood-vessels. 

Symptoms.  These  usually  begin  with  disturbance  of  the  speech;  there  is 
diflSiculty  in  articulating  the  Unguals,  R,  L,  D,  T,  the  voice  is  nasal  in  quality, 
the  tongue  becomes  atrophied  and  paralyzed;  swallowing  is  difficult  and 
mastication  imperfect.  \Vlien  the  muscles  of  the  lips  become  involved  the 
articulation  of  the  labials,  B,F,  P,  V,  becomes  imperfect  and  the  lips  are  thin 
and  tremulous,  the  facial  expression  is  changed  and  the  saliva  dribbles.  With 
involvement  of  the  pharynx  and  larynx,  swallowing  becomes  impossible, 
food  may  be  regurgitated,  or  drop  into  the  larynx  and  cause  foreign  body 
pneumonia;  the  voice  becomes  low,  monotonous  and  is  finally  lost.  Fine  con- 
tractions of  the  involved  muscles  may  be  observed.  There  are  no  changes  of 
sensation  and  taste  is  not  affected.  The  course  of  the  disease  is  chronic 
and  may  last  over  a  period  of  several  years. 

The  prognosis  is  hopeless,  death  taking  place  from  obstruction  of  the 
larynx  by  food  particles,  septic  pneumonia  or  exhaustion. 

Treatment  consists  in  the  employment  of  all  possible  means  to  maintain 
the  patient's  strength,  and  in  the  use  of  tonics,  such  as  iron,  arsenic,  quinine 
and  strychnine.  When  there  is  a  syphilitic  element  in  the  history  the  use  of 
mercury  and  potassium  iodide  is  indicated.  Electricity  may  confer  some 
benefit;  the  galvanic  current  may  be  employed  by  placing  the  electrodes, 
one  at  each  mastoid  process,  and  faradism  may  act  as  a  tonic  upon'the  affected 
muscles.  Galvanism  may  aid  the  patient  in  swallowing,  the  anode  being 
placed  at  the  back  of  the  neck  and  the  cathode  at  the  side  of  the  larynx;  when 
the  latter  is  moved  along  this  organ  it  causes  a  reflex  deglutatory  act. 

It  is  often  advisable  to  begin  to  feed  the  patient  by  means  of  the  stomach 
tube  early  in  the  disease. 

ACUTE  ASCENDING  PARALYSIS. 

Synonym.     Landry's  Paralysis. 

Definition.  An  acute  disease  characterized  by  rapidly  advancing  paralysis 
beginning  in  the  legs,  progressing  upward  to  the  body  and  finally  reaching 
the  arms,  causing  death  by  involving  the  respiratory  center  in  the  medulla. 


ACUTE    ASCENDING    PARALYSIS.  769 

etiology.  This  disease  affects  males  more  often  than  females  and  is  usually 
seen  in  healthy  individuals  in  the  prime  of  life  (twenty  to  forty).  Cases  have 
been  observed  in  which  the  abuse  of  alcohol  has  seemed  to  be  a  considerable 
factor  in  predisposing  to  the  condition  and  the  same  may  be  said  of  syphilis. 
Of  late  there  is  more  and  more  inclination  to  attribute  the  affection  to  a  toxic 
infection  of  the  peripheral  nerves  and  spinal  cord,  since  it,  at  times,  occurs 
as  a  sequela  of  microbic  diseases  such  as  enteric  fever,  erysipelas,  epidemic 
influenza,  etc. 

Pathology.  The  lesions  found  post  mortem  differ  but  it  seems  sure  that 
the  peripheral  motor  neurons  are  the  seat  of  chief  involvement;  changes  are 
also  observed  in  the  spinal  cord  resembling  those  of  acute  general  myelitis 
or  very  similar  to  those  occurring  in  peripheral  neuritis. 

Symptoms.  Prodromata,  such  as  loss  of  appetite,  rise  of  temperature, 
pains  in  head  and  back,  general  malaise  and  tingling  sensations  in  the  extrem- 
ities, lasting  from  a  few  hours  to  several  days,  are  usually  present.  Follow- 
ing these  a  rapidly  augmenting  weakness  of  the  legs  appears,  which,  within  a 
few  hours  or  a  few  days,  may  become  a  complete  paralysis.  The  paralysis 
soon  extends  to  the  trunk  and  in  a  day  or  two,  or  even  less  time  the  arms  are 
involved.  As  the  muscles  of  the  neck  and  face  become  affected  breathing 
is  interfered  with,  the  speech  becomes  Jndistinct,  swallowing  is  difficult  and 
other  symptoms  of  bulbar  paralysis  develop  and  death  occurs  from  respiratory 
paralysis.  The  reflexes  are  diminished  or  lost  but  may  later  return  and  become 
exaggerated,  the  sphincters  remain  continent,  there  is  no  muscular  atrophy 
or  tendency  to  bed-sores  and  the  electric  reaction  usually  remains  normal 
but  exceptionally  there  is  loss  of  faradic  excitability.  As  a  rule  sensation 
is  not  affected,  except  for  the  tingling  occurring  at  the  onset  and  the  develop- 
ment of  certain  hyperaesthesiae.  Vaso-motor  disturbances  evidenced  by  oedema 
and  hyperidrosis  may  be  present.  There  is  no  mental  impairment  and  seldom 
any  febrile  movement.  Rarely  patients  have  been  observed  in  whom  the 
paralysis  has  been  of  the  descending  type,  the  upper  part  of  the  body  being 
involved  first.  Death  may  supervene  here  from  involvement  of  the  medulla 
before  the  paresis  reaches  the  lower  limbs. 

The  course  of  the  disease  may  last  but  a  few  days  before  the  fatal  outcome 
or  it  may  continue  for  several  weeks,  depending  upon  whether  or  not  the  vital 
centers  are  affected. 

The  prognosis  is  generally  very  unfavorable  but  in  rare  cases  the  symp- 
toms have  gradually  ameliorated  and  recovery  has  ensued. 

Treatment.  The  patient  should  be  confined  to  his  bed  and  counter-irri- 
tation applied  to  the  spine  by  means  of  dry  cupping,  mustard  pastes  or  the 
thermo-cautery.  The  bowels  should  be  opened  by  repeated  small  doses  of 
calomel  followed  by  a  saline  and  the  activity  of  the  skin  and  kidneys  stimu- 
lated by  diaphoretics,  the  warm  bath,  and  the  potassium  salts  (potassium 
49 


77°  DISEASES    OF    THE    NERVOUS    SYSTEM. 

citrate  or  acetate,  gr.  X  to  XX — 0.66-1.33 — three  times  a  day)  in  order  to  assist 
in  the  elimination  of  the  toxin  causative  of  the  disease.  If  there  is  suspicion 
of  syphilis,  mercury  biniodide,  gr.  -gV  ~  To  (0.0012-0.002)  three  times  a  day 
should  be  given.  The  use  of  ergotine  is  recommended  by  Gowers,  he  having 
administered  gr.  xx  (1.33)  in  divided  doses  hourly  with  improvement  of  the 
symptoms,  followed  by  recovery.  The  salicylates  also  are  advocated  and  iron 
perchloride  may  be  employed  although  it  is  probable  that  these  drugs  will 
influence  the  progress  of  the  disease  but  little.  The  symptoms  of  respiratory 
or  cardiac  failure  should  be  combated  by  the  application  of  the  electric 
current  to  the  muscles  of  the  chest  and  to  the  phrenic  nerve  and,  in  the 
patients  who  survive  the  acuity  of  the  disease,  this  means  should  be  employed 
to  aid  muscular  and  nerve  regeneration. 

The  patient  should  lie  upon  the  side  rather  than  upon  the  back  since  the 
latter  position  tends  to  augment  the  congestion  of  the  spinal  cord.  When 
swallowing  becomes  difficult  the  use  of  the  stomach  tube  may  be  necessary 
in  order  to  maintain  the  patient's  nutrition  and  to  prevent  the  lodgment  of 
food  particles  in  the  respiratory  tract. 

SYRINGOMYELIA. 

Definition.  A  condition  of  the  spinal  cord  characterized  by  the  existence 
in  its  substance  of  abnormal  cavities  which  usually  contain  liquid  and  are 
surrounded  by  an  increase  of  neuroglia  tissue. 

.Etiology.  This  disease  may  exist  as  the  result  of  a  congenital  anomaly, 
of  the  degeneration  of  embryonal  or  gliomatous  tissue  in  the  cord  or  of  a 
haemorrhage,  traumatic  or  due  to  arterial  disease,  into  the  cord  substance. 

Pathology.  The  spinal  membranes  remain  normal  but  the  surface  of  the 
cord  is  irregular,  protuberances  being  seen  in  certain  places,  retractions  in 
others.  Over  the  prominences  fluctuation  may  be  obtained  and  puncture 
may  reveal  the  presence  of  serous  fluid.  The  cavities  may  be  multiple, 
extending  considerable  distances  up  or  down  the  cord,  being  usually  largest 
in  the  upper  dorsal  and  cervical  regions,  and  may  involve  nearly  the  whole 
diameter  of  the  structure  even  to  the  pons,  converting  it  into  a  tube.  The 
cavity  may  appear  to  be  a  dilatation  of  the  central  canal  or  it  may  be  situated 
in  the  posterior  portion  displacing  the  central  canal  forward.  The  cavity 
is  lined  with  neuroglia  which  may,  before  it  degenerates  and  becomes  softened, 
interfere  with  the  function  of  the  normal  tissue  of  the  cord.  Upon  the  out- 
skirts of  this  neuroglia  the  blood-vessels  are  more  numerous  than  normal, 
they  may  be  dilated  and  their  walls  may  be  the  seat  of  sclerotic  change. 

Symptoms.  While  mild  types  of  the  disease  may  be  evidenced  by  no  symp- 
toms, the  onset  usually  occurs  at  from  twelve  to  twenty  years  of  age  and  is 


morvan's  disease.  771 

of  gradual  development.  The  symptoms  depend  upon  the  situation  of  the 
lesion  and  consequently  the  neck,  arms  and  upper  thorax  are  most  affected. 
The  characteristic  symptoms  are  disorders  of  sensation,  particularly  of  the 
pain  and  temperature  senses;  touch  is  seldom  affected  but  may  be  rendered 
less  acute  than  normal.  These  disturbances  chiefly  involve  the  upper  part 
of  the  body,  but  areas  of  pain  sense  disturbance  may  be  observed  in  any 
part.  Muscular  w^eakness  may  occur  and  trophic  changes  in  the  skin 
and  nails  as  evidenced  by  thickening,  eruptions,  or  superficial  gangrene  of 
the  former  and  corrugation,  fissuring  or  even  loss  of  the  latter.  The  absence 
of  pain  sense  may  result  in  neglect  of  injuries  and  consequent  superficial 
infectious  processes  and  ulceration.  Sweating,  blueness,  coldness,  oedema 
and  other  vaso-motor  disturbances  may  be  observed.  The  joints  of  the  upper 
extremities  may  become  swollen,  their  cavities  filled  with  fluid  and  their 
articular  surfaces  absorbed,  a  change  analogous  to  that  occurring  in  locomotor 
ataxia.  The  bones  become  brittle  and  are  easily  fractured  and  spinal  curva- 
tures may  appear  as  a  result  of  the  atrophy  of  the  muscles  or  involvement 
of  the  vertebrae.     Secondary  contractures  of  the  hands  may  develop. 

When  the  disease  affects  the  medulla  there  may  be  partial  laryngeal  paral- 
ysis, dysphagia,  lingual  and  facial  paresis  and  disturbances  of  the  heart 
action  and  respiration.     The  pupils  may  react  sluggishly  or  be  unequal. 

Involvement  of  the  lumbar  cord  may  produce  paralyses  of  the  rectum  and 
bladder. 

The  prognosis.  The  course  of  the  disease  is  chronic,  extending  over  from 
ten  to  twenty  years;  its  development  is  slow  but  as  it  nears  its  termination  it 
progresses  more  rapidly.  The  ultimate  result  is  invariably  fatal,  death  super- 
vening from  exhaustion  or  involvement  of  the  medulla. 

Treatment.  This  is  entirely  without  avail  as  far  as  checking  the  disease 
is  concerned.  The  patient's  strength  should  be  maintained  by  nourishing 
food,  tonics  may  be  given  and  the  administration  of  arsenic  and  silver  has 
been  recommended.  The  patient  should  be  warned  of  the  danger  of  trau- 
matism and  fracture  and  he  should  be  protected  against  possible  injury. 
Otherwise  the  treatment  consists  in  the  relief  of  the  symptoms  as  they  appear. 

MORVAN'S  DISEASE. 

This  is  a  condition  analogous  to  syringomyelia  and  characterized  by  prac- 
tically identical  symptoms;  necrotic  infections  due  to  trophic  disorders  are 
likely  to  be  more  severe.  The  bacillus  lepra  has  been  found  in  the  degener- 
ated tissue  in  the  cavity  of  the  cord  in  certain  cases.  It  is  probable  that 
further  study  will  show  that  the  so-called  Morvan's  disease  is  identical  with 
syringomyelia. 


772  DISEASES    OF    THE    NERVOUS    SYSTEM. 

HAEMORRHAGE  INTO  THE  SPINAL  CORD. 

This  is  of  rare  incidence;  it  is  met  most  frequently  between  the  ages  of  twenty 
and  forty  although  it  has  been  observed  during  infancy.  The  condition  may 
result  from  traumatism,  it  may  occur  in  hasmophilic  subjects,  in  conditions 
of  asphyxia,  illuminating  gas  poisoning,  for  instance,  in  the  severe  convul- 
sions of  epilepsy,  eclampsia,  tetanus,  etc.,  after  excessive  coitus  and  as  the 
result  of  aneurysmal  rupture  or  arterial  disease.  The  haemorrhages  may 
be  single  or  multiple,  are  usually  in  the  gray  matter  and  may  be  sufficiently 
large  in  quantity  to  burst  through  the  white  substance  to  the  pia.  After  the 
extravasation  of  the  blood  the  tissues  of  the  cord  become  soft,  degenerated 
red  blood  cells  and  leucocytes  and  small  round  cells  are  seen  and  the 
cord  substance  is  tinged  with  the  coloring-matter  of  the  blood.  Later  the 
involved  area  may  develop  into  a  connective  tissue  cicatrix,  become  the 
seat  of  fatty  degeneration,  or  the  clot  may  be  absorbed,  leaving  a  cavity 
behind. 

Symptoms.  The  onset  of  this  condition  is  usually  sudden  with  feelings 
of  numbness  quickly  followed  by  paralysis  of  the  lower  limbs,  with  loss  of 
sensation  and,  perhaps,  ataxia;  there  is  loss  of  vesical  and  rectal  control, 
the  reflexes  are  lost  but  soon  return  and  become  increased;  there  may  be 
severe  pain  referred  to  the  spine  or  to  the  abdomen,  chest  or  limbs.  If  the 
upper  dorsal  or  the  cervical  region  is  involved  the  arms  and  chest  are  affected. 
The  acuity  of  the  symptoms  lessens  after  about  a  week  and  the  condition 
then  resembles  that  present  in  chronic  myelitis.  Spasmodic  contractions 
may  appear  and  muscular  atrophy  may  ensue  resulting  from  injury  of  the 
anterior  horn  cells.  If  the  extravasation  of  blood  is  large,  improvement  may 
not  take  place  and  the  affection  may  result  in  death  with  symptoms  of  acute 
myelitis. 

The  characteristic  symptoms  of  spinal  haemorrhage  are  the  very  sudden 
onset  and  the  pain. 

The  prognosis  is  dependent  upon  the  situation  and  volume  of  the  haem- 
orrhage.    It  is  least  serious  in  the  dorsal  region,  most  in  the  cervical. 

Treatment.  The  patient  should  be  put  to  bed  and  kept  absolutely  at  rest, 
cold  applications  should  be  made  to  the  spine  in  the  form  of  ice  bags  and 
the  circulatory  irritability  should  be  lessened  by  the  administration  of  aconite; 
restlessness  may  be  controlled  by  the  bromides.  Otherwise  the  treatment 
is  entirely  symptomatic.  Ergot  has  been  recommended  and  may  be 
tried. 

The  treatment  of  the  chronic  stage  consists  in  the  exhibition  of  the  iodides 
in  the  hope  of  lessening  the  tendency  to  the  production  of  connective  tissue 
growth  at  the  site  of  the  lesion,  together  with  the  employment  of  the  other 
means  discussed  under  the  treatment  of  chronic  myelitis  (p.  753). 


COMPRESSED-AIR    DISEASE.  773 

COMPRESSED-AIR  DISEASE. 

Synonyms.  Caisson  Disease;  Diver's  Paralysis;  "The  Bends." 

Definition.  A  disease  caused  by  suddenly  emerging  from  air  under  high 
pressure  into  that  of  normal  pressure,  and  characterized  by  dizziness,  pains 
in  the  head  and  joints,  especially  the  knees  and  elbows,  and  in  severer  instances 
by  motor  and  sensory  paralyses  of  the  legs  of  greater  or  less  degree. 

Etiology.  This  condition  is  met  in  artisans  who  have  been  working 
under  heavy  atmospheric  pressure  in  caissons  such  as  are  employed  in  the 
construction  of  subaqueous  tunnels,  bridges,  piers,  foundations  of  buildings 
and  the  like.  The  disease  seems  to  depend  upon  disturbance  of  the  central 
nervous  system  caused  by  the  sudden  change  of  atmospheric  pressure  atten- 
dent  upon  emergence  from  caissons,  in  which  the  pressure  may  be  as  high 
as  sixty  pounds  to  the  square  inch  in  excess  of  the  normal  fifteen  pounds, 
into  the  ordinary  atmosphere.  Some  persons  seem  to  be  more  susceptible 
to  the  disorder  than  others  and  it  is  unlikely  to  occur  unless  the  individual 
has  been  subjected  to  the  pressure  for  an  hour  or  more.  Those  unaccustomed 
to  working  under  pressure  are  more  likely  to  be  attacked  than  those  regularly 
engaged.     The  status  lymphaticus  may  be  considered  a  predisposing  cause. 

Pathogenesis  and  Pathology.  Various  theories  of  the  pathogenesis  of 
this  disease  have  been  advanced  but  in  the  light  of  recent  research  it  seems 
probable,  if  not  certain,  that  it  is  the  result  of  gas  emboli  in  the  circulating 
blood.  Air  under  pressure,  according  to  experiments  performed  by  Brooks, 
is  absorbed  by  inert  fluids,  by  certain  inert  tissues,  and  by  dead  and  living 
animal  tissues,  and  the  amount  of  absorption  depends,  to  a  great  degree, 
on  the  degree  of  the  compression,  according  to  Dalton's  law;  on  release  of  the 
pressure  air  is  liberated  from  these  substances  in  quantity  according  to  the 
degree  of  previous  absorption.  When  rapid  liberation  takes  place  in  dead 
or  living  animal  bodies,  it  causes  dilatation  of  the  lymph  passages,  rupture  of 
the  capillaries  and  the  production  of  tissue  laceration  by  the  escaping  gas 
bubbles.  Frequent  repetition  of  these  lesions  in  living  tissues  causes  endo- 
thelial and  interstitial  proliferation  with  tissue  necrosis  in  and  about  the 
diseased  vessels  and  eventual  secondary  inflammatory  changes. 

The  symptoms  of  compressed-air  disease  admit  of  this  explanation  and 
the  clinical  manifestations  are  produced  in  this  manner.  They  are  succeeded 
in  sub-acute  or  chronic  instances  of  the  affection  by  secondary  degenerative 
inflammatory  lesions  which  may  be  grouped  as  myelitis.  In  View  of  these 
facts  it  seems  justifiable  to  conclude  that  the  essential  aetiologic  factor 
is  the  rapid  liberation  of  gas  from  the  body  fluids  and  tissues  when  decompres- 
sion is  allowed  to  take. place  too  rapidly.  This  liberation  of  gas  bubbles 
causes  laceration  of  the  soft  tissues,  dilatation  of  the  lymph  spaces  and  ca- 
pillary haemorrhages. 


774  DISEASES    OF    THE    NERVOUS    SYSTEM. 

At  autopsies  upon  bodies  of  patients  dead  from  compressed-air  disease, 
free  gas  is  found  in  the  chambers  of  the  heart,  in  the  arteries,  capillaries,  and 
in  the  lymph  spaces;  capillary  ruptures  are  found  and  diffuse  parenchymat- 
ous myelitis,  with  degeneration  in  the  posterior  and  in  the  adjoining  lateral 
columns  of  the  cord,  has  been  demonstrated  in  subjects  who  have  survived 
long  enough  for  such  changes  to  take  place. 

Symptoms.  Individuals  suffering  from  compressed-air  illness  usually 
exhibit  the  affection  in  one  of  four  main  types: 

1.  "The  Bends."  This  is  the  mildest  form  of  caisson  disease  and  is  char- 
acterized by  pains  of  varying  severity.  These  are  most  common  in  the  limbs; 
one  limb  or  all  may  be  affected,  but  the  legs  suffer  more  commonly  than  do 
the  arms.  The  pains  may  be  extremely  severe;  they  are  continuous,  as  a 
rule,  but  paroxysmal  exacerbations  may  be  observed.  The  pain  is  increased 
on  motion,  but  there  is  no  swelling,  and  tenderness  is  sometimes  not  notable. 
Itching  of  the  skin  is  a  frequent  symptom.  Abdominal  cramps  are  not  uncom- 
mon, and  a  condition  termed  "/Ae  chokes"  is  occasionally  seen.  This  is 
characterized  by  cough,  a  sense  of  oppression  of  the  chest,  and  some  difficulty 
in  respiration.  The  symptoms  described,  like  all  the  manifestations  of  com- 
pressed-air illness,  usually  appear  within  an  hour  after  emergence  from  the 
compressed  air.  Under  treatment  the  pains  disappear,  as  a  rule,  but  they 
may  be  persistent,  and  sometimes  reappear  after  apparent  recovery. 

2.  "  The  Staggers."  This  type  of  compressed-air  illness  is  character- 
ized by  dizziness  and  staggering.  At  times  the  latter  may  be  so  marked  that 
the  patient  falls,  usually  to  one  side  Cr  the  other,  unless  he  is  supported. 
Vomiting  may  be  present  and  the  pulse  may  be  rapid  and  weak.  Spots  may 
appear  upon  the  skin  of  the  abdomen,  back,  and  limbs;  these  are  purplish 
in  color,  and  vary  in  size  from  that  of  a  finger-nail  to  that  of  a  quarter-dollar. 
There  may  be  dimness  of  vision  and  nystagmus.  The  condition  of  the  pupil 
is  variable.  The  hearing  is  often  diminished  in  acuity,  but  the  patient  will 
usually  answer  rationally  upon  loud  questioning.  There  is  seldom  any  men- 
tal disturbance.  Pains  in  the  limbs  or  abdomen  may  be  present,  and  numb- 
ness of  the  extremities  may  be  noted. 

3.  The  Paralytic  Type.  The  motor  and  other  symptoms  of  this  type 
of  the  affection  are  in  no  way  characteristic.  The  loss  of  motility  may  be 
gradual  or  sudden,  and  there  may  be  monoplegia,  hemiplegia,  or  paraplegia; 
the  last  is  perhaps  more  common.  Sensation  may  be  delayed  or  absent,  or 
there  may  be  irregular  areas  of  anaesthesia  which  sometimes  occur  without 
paralysis.  The  reflexes  may  be  normal,  lost,  or  exaggerated,  and  a  spastic 
condition  of  the  limbs  has  been  noted.  There  frequently  is  retention  of  urine 
necessitating  catheterization;  more  rarely  there  is  paralysis  of  the"  bladder 
and  the  rectum,  with  incontinence.     The  mind,  as  a  rule,  remains  clear. 

The  paralyses  ma/  disappear  permanently  upon  treatment;  they  may  be 


COMPRESSED-AIR    DISEASE.  775 

temporarily  relieved,  to  occur  again,  or  they  may  resist  all  efforts.  As  a 
rule,  however,  they  are  not  permanent,  although  months  may  elapse  before 
entire  recovery  takes  place. 

4-  The  Comatose  Type.  In  this  type  the  most  prominent  symptom  is 
partial  or  complete  coma,  which  may  appear  suddenly  after  emergence  from 
the  pressure  or  may  be  preceded  by  other  manifestations  of  the  affection,  more 
particularly  those  described  under  the  second  form  of  the  disease.  In  the 
semi-conscious  patients  active  delirium  may  be  present.  The  coma  of  caisson 
disease  is  in  no  way  characteristic.  The  patient  may  suddenly  become  uncon- 
scious and  die  within  an  hour,  or  less,  of  cardiac  or  respiratory  failure,  the 
pulse  growing  weaker  and  weaker  and  the  respiration  increasingly  slower 
until  the  end  ensues.  Comatose  patients  usually  exhibit  cyanosis  of  the  lips 
and  face.  The  skin  is  moist  with  a  cold  perspiration;  the  pupils  may  be 
normal,  dilated,  contracted,  or  unequal;  their  reaction  may  be  sluggish  and 
nystagmus  may  be  observed.  The  pulse  is  often  w^eak,  thready,  and  irregular, 
and  the  respiration  stertorous.  There  may  be  frothing  at  the  mouth,  nose- 
bleed, vomiting,  sometimes  with  blood,  and  the  rectum  and  bladder  may 
be  incontinent.  The  limbs  may  be  flaccid  or  rigid,  or  there  may  be  con- 
vulsive movements.  The  reflexes  are  in  no  way  typical.  The  temperature 
may  be  normal  or  elevated.  A  fatal  outcome  is  the  rule  in  almost  all  instances 
in  which  absolute  coma  is  present. 

The  foregoing  classification  should  not  be  considered  absolute,  since  the 
symptoms  of  the  various  groups  are  often  so  interwoven  as  to  make  arbitrary 
division  quite  impossible. 

Prevention.  Toward  prophylaxis  of  the  affection  much  can  be  accom- 
plished by  taking  certain  precautions.  All  applicants  for  work  under  pres- 
sure should  be  subjected  to  as  rigid  a  physical  examination  as  that  considered 
necessary  for  an  individual  applying  for  life  insurance. 

The  conclusions  may  be  drawn  that  the  laborer  in  compressed  air  should 
not  be  younger  than  twenty  nor  older  than  thirty-five  years,  that  his  muscular 
system  should  be,  at  least,  normally  developed,  that  his  eyes  and  ears  should 
be  normal,  and  that  his  general  physical  condition  should  be  in  no  way  viti- 
ated. It  is  usually  the  part  of  wisdom  to  disqualify,  at  least  temporarily,  sub- 
jects whose  pulse  is  too  rapid  (above  loo)  or  irregular,  as  well  as  those  who 
give  evidence  of  cardiac,  arterial,  pulmonary,  hepatic,  or  renal  disease.  Alco- 
holism, unless  the  applicant  exhibits  the  signs  of  this  condition  in  its  acute 
stage,  is  not  a  reason  for  disqualification,  else  it  would  be  most  difficult  to 
obtain  workers.  Observation  seems  to  show  that  the  negro  and  the  Anglo- 
Saxon  races  are  less  subject  to  the  evil  effects  of  air  under  pressure  than  are 
Italians,  Poles,  and  other  Eastern  Europeans. 

It  has  been  held  by  pathologists,  who  have  made  autopsies  upon  subjects 
dead  of  compressed-air  illness,  that  status  lymphaticus  is  often  present,  and 


776  DISEASES    OF    THE    NERVOUS    SYSTEM. 

consequently  the  signs  of  this  condition  should  be  sought  as  a  part  of  the 
routine  physical  examination. 

After  having  passed  a  satisfactory  examination  the  candidate  should  be 
subjected  to  a  preliminary  test,  that  is  to  say,  he  should  be  put  under  a  pressure 
of  from  twenty-five  to  thirty  pounds  for  an  hour  and  a  half;  following  this  he 
should  undergo  a  second  physical  examination,  and  should  there  be  no  reason 
for  his  disqualification,  he  may  be  allowed  to  undertake  work  in  the  compressed 
air,  after  having  received  certain  warnings  and  advice,  as  follows:  The 
air  chamber  should  not  be  entered  unless  the  subject  feels  perfectly'  well, 
and  it  is  unwise  to  begin  work  on  an  empty  stomach.  Intoxicants  should 
be  used  sparingly,  or,  better,  not  at  all;  but  little  water  should  be  drunk  while 
under  pressure,  and  the  laborer  should  obtain  at  least  seven  hours'  sleep  per 
day.  As  the  pressure  is  raised  the  fulness  in  the  ears,  which  is  caused  by 
the  difference  in  the  pressure  outside  the  membrana  tympani  and  that  within 
this  structure,  may  be  relieved  by  swallowing  or  by  closing  the  mouth,  holding 
the  nostrils,  and  performing  the  act  of  blowing  the  nose.  This  forces  the 
Eustachian  tubes  open  and  thus  equalizes  the  pressure.  Emergence  from  the- 
compressed  air  must  be  slow;  at  least  fifteen  minutes  (and  still  better,  thirty) 
should  be  taken  to  come  out  from  a  pressure  of  thirty  pounds,  the  pressure 
being  allowed  to  fall  not  faster  than  two  pounds  per  minute.  The  laborers 
should  come  out  of  the  pressure  as  follows:  At  the  end  of  the  shift  they  enter 
the  air  lock,  the  pressure  in  which  is  equal  to  that  in  the  caisson  where  they 
have  been  working.  The  door  between  the  caisson  and  the  air  lock  should 
be  closed  and  the  exit  valve  of  the  latter  opened  sufficiently  to  allow  a  slow 
and  gradual  outflow  of  the  compressed  air.  When  this  has  escaped  and  the 
pressure  within  the  lock  has  become  equal  to  that  outside,  the  laborers  should 
be  liberated.  After  coming  out  hot  coffee  should  be  drunk  freely,  and  warm, 
dry  woolen  clothing  should  be  put  on.  All  exposure  to  cold  should  be  avoided 
and  no  undue  exercise  should  be  undertaken  for  at  least  an  hour  after  emer- 
gence. Beer  or  other  cold  liquids  should  not  be  drunk  for  a  considerable 
period  after  leaving  pressure. 

If  the  caisson  is  underground  elevatt)rs  should  be  provided  to  bring  the 
laborers  to  the  surface,  for  the  climbing  of  ladders  seems  to  predispose  to 
the  occurrence  of  the  evil  effects  of  working  in  compressed  air. 

Treatment.  In  the  treatment  of  all  types  of  compressed-air  illness  the 
first  consideration  is  recompression  of  the  patient,  that  is  to  say,  he  must 
be  subjected  to  the  further  influence  of  compressed  air.  For  this  purpose 
so-called  hospital  locks  should  be  provided.  Such  a  lock  may  consist  of  a 
horizontal  cylinder  made  of  one-half  to  three-quarter  inch  boiler  iron;  a  very 
practical  size  is  about  twenty-five  feet  in  length  by  seven  feet  in  diameter. 
The  lock  should  be  divided  into  two  chambers  by  a  partition  in  which  is  an 
air-tight  door  opening  inward.     The  open  end  of  the  lock  should  be  fitted 


COMPRESSED-AIR    DISEASE.  777 

with  a  similar  door.  The  double-chambered  lock  is  the  most  practical  type, 
for  since  both  chambers  are  supplied  with  outlet  and  inlet  valves,  a  means 
is  thus  afforded  whereby  the  patient  can  be  visited  by  an  attendant  without 
reducing  the  pressure  to  which  the  former  is  being  subjected. 

Usually  when  the  patient,  if  suffering  merely  from  the  first  type  of  the 
affection,  and  especially  if  he  has  applied  for  treatment  soon  after  the  onset 
of  his  symptoms,  is  subjected  to  recompression  he  experiences  very  striking 
relief,  the  pains  disappearing  entirely  long  before  the  height  of  pressure  in 
which  he  has  been  accustomed  to  work  has  been  reached.  The  pressure  is 
allowed  to  rise,  even  after  relief  is  evident,  to  a  height  equal  to  that  in  which 
the  patient  has  been  working,  and  then  he  is  "decompressed,"  tliat  is, 
the  pressure  is  slowly  lowered  to  normal  at  the  rate  of  about  one-half 
pound  per  minute.  Even  slower  decompression  may  be  advisable  in  severe 
forms  of  the  disease.  Valves  are  obtainable  which  so  control  the  outlet  of  air 
that  the  time  necessary  for  the  outflow  of  a  given  amount  is  the  same  whether 
the  pressure  within  the  lock  be  high  or  low.  It  must  not  be  forgotten  thai 
it  is  necessary  to  supply  the  lock  with  a  certain  amount  of  fresh  air  after  the 
inlet  valve  has  been  closed,  otherwise  the  patient  would  be  in  danger  of  suffo- 
cation. 

In  treating  instances  of  compressed-air  disease  it  is  unwise  to  subject  the 
patient  to  the  maximum  pressure  for  more  than  five  or  ten  minutes.  When 
relief  is  experienced  from  the  pain  of  an  ordinary  attack  of  the  "bends"  the 
patient  is  directed  to  move  about  the  lock  and  to  exercise  and  rub  the  affected 
part  with  a  counterirritant  ointment.  In  most  of  the  mild  'cases  the  patient 
leaves  the  lock  wholly  relieved,  but  if  there  is  a  return  of  the  pain  recom- 
pression is  advisable,  the  pressure  being  allowed  to  ascend  until  the  pains 
disappear,  when  slow  decompression  is  instituted  as  before.  A  third  or 
even  a  fourth  recompression  may  be  employed  if  necessary,  but  usually  the 
relief  experienced  from  these  subsequent  treatments  is  temporary  and  slight 
in  character.  It  is  wise,  if  there  is  still  continuation  of  the  pain  after  the  patient 
has  been  sufficiently  recompressed,  to  advise  thorough  rubbing  of  the  pain- 
ful part  with  a  counter-irritant  ointment  or  liniment.  The  following  are 
suggested:  Capsicum  oleoresin  2  parts,  oil  of  turpentine  5  parts,  oil  of  rose- 
mary 5  parts,  camphor  5  parts,  olive  oil  5  parts,  petrolatum  sufficient  to  make 
100  parts;  or  menthol  10  parts,  methyl  salicylate  5  parts,  hydrated  chloral 
10  parts,  lanolin  to  100  parts.  The  faradic  current,  applied  as  strong  as  can 
be  comfortably  borne,  and  the  high-frequency  current  and  vibratory  massage, 
may  prove  beneficial;  hot  baths,  hot-water  bags,  and  the  electrotherm,  are 
very  helpful  adjuncts.  Ironing  the  painful  part  with  a  hot  flat-iron,  a  flannel 
cloth  being  interposed  between  it  and  the  skin,  is  also  suggested. 

The  persistent  pains  may  be  relieved  by  analgesics,  such  as  salipyrine  10 
grains  (0.66)  every  two  hours,  acetanilide  5  grains  (0.33)  every  four  hours, 


778  DISEASES    OF    THE    NERVOUS    SYSTEM. 

or  acetphenetidine  lo  grains  (0.66)  every  three  hours.  These  drugs  should  be 
given  with  care,  and,  if  there  is  any  tendency  to  heart  weakness,  they  should 
be  combined  with  citrated  caffeine.  Codeine  may  also  be  prescribed.  Rarely 
are  the  symptoms  severe  enough  to  warrant  the  employment  of  morphine.  In 
the  management  of  all  forms  of  the  condition  other  than  that  characterized 
by  pain,  little  in  the  way  of  specific  treatment  aside  from  decompression  can 
be  done. 

Much,  however,  can  be  accomplished  in  the  more  serious  types  by  the 
employment  of  symptomatic  measures:  when  cardiac  or  respiratory  weakness 
is  evident  hypodermatic  stimulation  with  strychnine,  adrenalin  chloride,  caSe- 
ine,  etc.,  should  be  resorted  to.  Artificial  respiration  may  be  indicated,  and 
stimulation,  by  means  of  enemas  of  hot  coffee,  is  always  advisable  in  comatose 
patients.  All  these  measures  may  be  applied  by  attendants  while  the  patient 
is  under  pressure  in  the  hospital  lock.  Sometimes  the  results  attained,  even 
in  patients  in  coma,  are  surprisingly  good.  Oxygen  may  be  administered 
if  there  is  respiratory  failure,  but  should  not  be  given  while  the  patient  is  under 
pressure. 

The  after-treatment  consists  in  careful  nursing,  feeding  with  nourishing 
food,  and  the  use  of  tonics.  Patients  affected  with  persistent  paralysis  should 
receive  the  routine  treatment  of  chronic  myelitis. 

COMPRESSION  OF  THE  SPINAL  CORD. 

Synonyms.     Compression  Myelitis;  Pressure  Paralysis  of  the  Spinal  Cord. 

Compression  of  the  spinal  cord  may  be  caused  by  various  lesions  and  results 
in  paralyses  differing  in  degree  and  character.  Among  the  causes  of  cord  com- 
pression may  be  mentioned  neoplasms,  syphilitic  and  inflammatory  thickenings 
of  the  spinal  membranes,  spondylitis,  particularly  that  due  to  tuberculous 
processes  (Pott's  disease),  malignant  new  growths  and  injuries  of  the  verte- 
bras, cysts  of  the  spinal  canal  due  to  the  echinococcus  or  the  cysticercus, 
erosion  of  the  vertebrae  and  consequent  pressure  upon  the  cord  due  to  aortic 
aneurysms,  malignant  retroperitonasal  neoplasms  and  collections  of  pus, 
retropharyngeal  abscesses,  etc. 

Pathology.  At  the  site  of  the  compression  the  cord  may  be  smaller  in 
size  than  normal,  and  irregular  in  outline  on  cross  section;  in  recent  lesions  it 
may  be  softened  but  in  compression  of  long  standing  its  consistence  may  be 
harder,  due  to  the  replacement  of  previously  degenerated  areas  by  connective 
tissue.  Microscopically,  the  nerve  fibres  are  swollen  and  fatty  degeneration 
may  be  observed,  later  this  condition  is  replaced  by  a  growth  of  connective 
tissue  of  more  or  less  firmness  depending  upon  the  duration  of  the  pressure. 
Ultimately,  secondary  ascending  and  descending  degenerations  may  occur. 

Symptoms.     In  the  most  common  variety  of  compression  myelitis — that 


COMPRESSION    OF    THE    SPINAL    CORD.  779 

resulting  from  Pott's  disease — the  deformity  may  have  existed  for  a  long 
period  before  any  symptoms  resulting  from  cord  compression  appear,  while  in 
instances  due  to  intra-thoracic  or  abdominal  lesions,  the  cord  symptoms  may  be 
noted  first.  Pain  is  an  early  symptom  and  varies  in  degree  from  a  dull  ache 
at  the  site  of  the  pressure  to  very  marked  pain.  The  discomfort  is  increased 
by  bending  the  back.  If  the  pressure  is  upon  the  nerve  roots  the  pain  may  be 
situated  in  the  distribution  of  the  nerves  having  their  origin  in  the  roots  affected. 
There  are  sensations  of  numbness  and  tingling.  Sensation  is  not  likely  to 
be  disturbed  although  anaesthesia  may  occur  in  lesions  of  long  standing. 
Later,  symptoms  of  motor  disturbance,  usually  not  symmetrical  at  first  but 
affecting  one  leg  or  arm  before  the  other,  may  be  noted;  these  consist  of 
muscular  stiffness  and  varying  disorders  of  motility  ultimately  becoming 
complete  paralysis. 

As  w^ould  be  expected  the  symptoms  differ  with  the  area  of  the  cord  affected. 
When  the  pressure  is  exerted  upon  the  upper  part  of  the  cord  just  below  the 
medulla,  movement  of  the  neck  may  be  accompanied  by  pain  and  the  neck 
muscles  may  be  the  seat  of  spastic  contractions;  in  marked  instances  it  may 
be  impossible  to  move  the  head.  If  the  lesion  is  in  the  lower  cervical  cord 
the  muscles  of  the  neck  may  be  rigid  while  sensory  and  motor  disturbances 
of  the  arms  may  occur.  The  skin  and  tendon  reflexes  are  increased,  because 
of  interference  with  the  passage  of  inhibitory  influences,  the  knee  jerk  is 
exaggerated  and  ankle  clonus  is  present. 

In  pressure  upon  the  dorsal  and  lumbar  regions  the  legs  only  are  affected 
although  in  lesions  involving  the  dorsal  cord  only,  there  is  likely  to  be  pain 
in  the  distribution  of  the  intercostal  nerves,  the  girdle  sensation  may  be- 
present,  and  there  is  ankle  clonus  with  augmented  patellar  reflex.  In  involve- 
ment of  the  lumbar  cord  there  are  motor  and  sensory  disturbances  in  the 
legs,  the  reflexes  are  diminished  and  vesical  and  rectal  incontinence,  pre- 
ceded by  difficult  micturition  and  constipation,  may  occur. 

Trophic  disorders  evidenced  by  a  tendency  to  bed-sores,  atrophy  of  the 
muscles  of  the  paralyzed  parts,  skin  eruptions,  desquamation  and  dryness 
of  the  nails  may  be  observed. 

The  prognosis  in  compression  due  to  Pott's  disease  is  good  because  of  the 
possibility  of  removing  the  cause  of  the  lesion,  in  that  due  to  other  causes 
it  is  unfavorable.  It  is  possible  for  the  symptoms  to  disappear  even  after 
they  have  endured  for  months. 

Treatment  varies  with  the  cause  of  the  condition;  that  of  Pott's  compres- 
sion consists  in  the  use  of  appliances  calculated  to  reduce  the  deformity  and 
in  the  administration  of  antituberculous  medication,  codliver  oil,  creosote, 
especially  in  the  form  of  the  carbonate,  iron,  arsenic  and  other  tonics  com- 
bined with  plenty  of  fresh  air,  proper  exercise  and  nourishing  food.  Suspen- 
sion has  been  employed  with  good  results  in  the  earlier  stages.     When  the 


ySo  DISEASES   OF    THE    NERVOUS    SYSTEM. 

condition  is  the  result  of  syphilitic  gummata  or  meningitis  the  administration 
of  mercury  and  potassium  iodide  is  indicated. 

The  pain  may  be  relieved  by  the  coal  tar  analgesics,  such  as  salipyrine, 
acetphenetidine,  acetanilide;  hydrated  chloral  and  morphine  may  be  employed 
as  last  resorts  only,  on  account  of  the  possibility  of  habit  formation.  When 
this  symptom  is  due  to  cervical  meningeal  thickening  counter-irritation  by 
means  of  the  electro-  or  thermo-cautery  may  be  beneficial. 

The  muscular  twitchings  should  be  combated  by  the  bromides. 

Rest  and  hydrotherapeutic  measures,  especially  warm  baths,  are  impor- 
tant adjuncts  to  treatment. 

Massage  and  electricity  influence  the  course  of  the  disease  not  at  all  but 
may  be  used  to  maintain  the  nutrition  of  the  atrophied  muscles. 

Compression  by  neoplasms  necessitates  surgical  intervention.  The  removal 
of  non-malignant  growths  may  be  followed  by  recovery,  that  of  malignant 
tumors  by  temporary  benefit  only,  as  a  rule. 

Laminectomy  is  necessary  in  conditions  of  fracture  and  dislocation  com- 
pression and  has  been  employed  in  tuberculous  spondylitis.  Surgical  treat- 
ment is  also  indicated  in  pressure  upon  the  cord  resulting  from  intra-thoracic 
and  intra-abdominal  abscesses.  Aneurysmal  compression  may  be  treated  by 
the  various  operations  advocated  for  the  relief  of  the  primary  condition. 

TUMORS  OF  THE  SPINAL  CORD  AND  ITS   MENINGES. 

Tumors  causing  symptoms  referable  to  the  spinal  cord  are  of  various  types 
and  origin.  They  may  arise  from  the  bones,  cartilages,  or  ligaments  of  the 
spinal  column — enchondroma,  sarcoma,  carcinoma — in  the  tissues  of  the 
extradural  space  and  from  the  outer  surface  of  the  dura — sarcoma,  carcinoma, 
lipoma  and  tumors  resulting  from  the  growth  of  hydatids  or  cysticerci — in 
the  spinal  membranes — sarcoma,  tuberculoma,  syphiloma  and  parasitic 
growths — in  the  substance  of  the  cord — glioma,  tuberculous  and  syphilitic 
tumors,  sarcoma  and  myxoma.  Mixed  tumors  in  any  of  these  situations 
may  occur.  The  tumors  most  commonly  found  are  those  due  to  syphilis 
and  tuberculosis,  and  sarcomata.  Parasitic  growths  are  seldom  met.  New 
growths  also  develop  in  the  spinal  nerve  roots  inside  the  dura;  these  may  be 
myxomata,  fibromata,  lipomata,  neuromata  or  tumors  of  mixed  character. 

Spinal  neoplasms  are  usually  single  but  multiple  neuromata  or  sarcomata 
sometimes  occur.  In  size  they  seldom  reach  a  greater  diameter  than  two 
inches  and  frequently  they  are  much  smaller  than  this;  when  within  the  spinal 
canal  their  growth  is  limited  by  its  calibre. 

Symptoms.  Slowly  developing  tumors  may  exist  for  considerable  periods 
before  causing  noticeable  symptoms;  when  these  appear  they  depend  upon 
the  site  of  the  growth  and  the  pressmre  exerted  by  it. 


TUMORS    OF    THE    SPINAL    CORD    AND    ITS    MENINGES.  781 

The  chief  symptoms  are  sensory  and  motor.  Pain  is  Hkely  to  be  the  earliest 
of  these  and  is  usually  due  to  the  pressure  of  the  tumor  upon  the  sensory 
nerve  roots.  It  is  of  varying  character.  It  may  be  a  dull  ache  or  a  burning, 
stabbing  pain  or  a  girdle  sensation.  Its  situation  differs  in  accordance  with 
the  nerve  roots  mvolved,  it  may  affect  one  or  both  sides  of  the  body, 
and  appears  first  at  the  termination  of  the  nerves  upon  which  the  pressure 
is  exerted.  There  may  be  anaesthetic  and  hyperaesthetic  areas.  Spinal 
pain,  increased  upon  motion,  and  tenderness  are  sometimes  present. 

Motor  symptoms  consist  of  spastic  contractions,  marked  oftentimes,  if 
the  tumor  is  meningeal,  and  muscular  rigidity  at  the  level  of  the  lesion;  this 
may  aid  in  diagnosticating  the  site  of  the  tumor.  Spasm  of  the  arm  and  leg 
of  one  side  suggests  a  tumor  on  the  corresponding  side  somewhere  in  the 
cervical  region,  whereas,  if  the  muscles  of  the  leg  only  are  affected,  the  growth 
is  likely  to  be  in  the  dorsal  cord.  Paralysis  gradually  develops  as  the  tumor 
increases  in  size  and  may  finally  become  complete.  If  the  neoplasm  is  in 
the  cervical  region  this  symptom  affects  both  arms  and  legs,  if  below  this  level 
the  lower  limbs  only.  The  paralysis  may  be  more  marked  on  one  side  if  the 
tumor  presses  more  upon  one  side  of  the  cord  than  upon  the  other. 

Sensation  is  finally  lost  in  the  paralyzed  parts  if  the  tumor  is  below  the  sixth 
dorsal  segment,  but  if  it  is  above  this  point  and  eccentric,  the  sensory  disturb- 
■  ance  is  likely  to  be  greater  upon  the  side  affected  by  the  smaller  amount  of 
motor  disturbance. 

Vaso-motor  disorders,  oedema,  mottling  of  the  skin,  etc.,  may  occur  and 
if  the  lesion  affects  the  cells  of  the  anterior  horns  muscular  atrophy  results. 
Ascending  and  descending  degeneration  of  various  tracts  of  the  cord  may 
occur  in  cases  of  long  standing,  and  true  myelitis  may  at  any  time  be  engrafted 
upon  the  primary  condition  and  obscure  the  diagnosis. 

The  typical  manifestations  of  spinal  tumor  are  the  gradual  appearance 
of  symptoms  referable  to  the  spinal  nerve  roots,  first  of  one  side,  later  of  the 
other,  and  the  development  of  motor  and  sensory  paralysis.  The  fact  that 
the  pain  is,  as  a  rule,  at  the  level  of  or  slightly  below  the  growth  (it  is  never 
above),  is  of  practical  value  in  ascertaining  the  seat  of  the  growth.  The  char- 
acter of  the  growth  is  difficult  of  diagnosis  unless  a  history  of  syphilis  or  the 
presence  of  tuberculous  disease  in  other  parts  of  the  body  can  be  made  out. 

Treatment.  This  depends  upon  the  cause  of  the  compression  and  natur- 
ally should  be  directed  toward  the  relief  of  that  condition.  The  treatment 
of  Pott's  disease  compression  consists  in  the  alleviation  of  the  deformity  by 
orthopaedic  apparatus  and  constitutional  treatment  directed  against  the  causa- 
tive tuberculous  infection.  The  means  at  our  disposal  are  the  administration 
of  codliver  oil  and  other  tonics,  the  insistence  upon  proper  hygiene  and  plenty 
of  nourishing  food. 

Compression  resulting  from  growths  of  syphilitic  tissue  necessitates  vigor- 


782  DISEASES    OF  THE    NERVOUS    SYSTEM. 

ous  anti-luetic  treatment;  in  that  due  to  tumors  of  gliomatous  or  sarcomatous 
type  arsenic  and  silver  nitrate  may  be  administered,  with  Httle  hope  of  benefit, 
however.  The  consideration  of  surgical  interference  is  pertinent  in  all  forms 
of  neoplasmic  compression  and  the  earlier  this  form  of  treatment  is  under- 
taken the  more  likely  will  it  be  to  relieve  the  condition.  Tumors  outside  the 
dura  are  not  difficult  of  removal,  and  even  those  in  the  cord  substance  may 
be  operated  upon  with  some  benefit.  When  there  is  certainty  of  the  presence 
of  a  new  growth  exploratory  operation  is  justifiable  and,  when  done  by  skillful 
hands,  is  of  comparatively  slight  danger. 


SPINAL  MENINGITIS. 
SPINAL  PACHYMENINGITIS. 

Definition.  An  inflammatory  condition  of  the  dura  mater  of  the  spinal 
cord. 

While  attempts  have  been  made  to  separate  the  inflammations  involving 
the  outer  layer  of  the  spinal  dura,  such  as  those  resulting  from  the  extension 
of  inflammations,  especially  tuberculous,  of  the  bones  of  the  spinal  canal, 
from  those  involving  the  inner  layer  of  this  structure,  it  is  both  difficult  and 
unnecessary  from  a  symptomatologic  as  well  as  from  a  pathologic  standpoint 
to  do  so  since  the  pachymeningitis  externa  rarely  exists  as  a  distinct  entity,  the 
inflammation  extending  in  almost  every  case  to  the  inner  layer  of  the  dura, 
a  pachymeningitis  interna  resulting,  with,  oftentimes,  an  involvement  of  the 
pia  of  the  cord  as  well. 

Of  pachymeningitis  interna,  two  forms  are  distinguished;  cervical  hyper- 
trophic pachymeningitis  and  hasmorrhagic  internal  pachymeningitis. 

The  former  is  a  chronic  inflammation  due  to  syphilitic  infection,  the  abuse 
of  alcohol  or  exposure  to  cold.  The  dura  of  the  cervical  region  is  involved 
to  a  greater  or  less  extent  of  its  area  and  pathologically  the  process  consists 
of  an  exudation  of  fibrinous  tissue,  occurring  in  successive  layers  upon  the 
inner  surface  of  this  membrane  and,  at  times,  resulting  in  adhesions  between 
it  and  the  adjacent  pia. 

Symptoms.  These  are  referable  to  the  compression  of  the  cord  by  the 
fibrinous  exudate  and  consist  of  pain  in  the  arms,  and  in  the  back  of  the  neck 
and  head;  with  this,  disorders  of  sensation,  numbness,  tingling  and  herpetic 
eruptions  may  be  observed.  These  symptoms  are  due  to  pressure  upon  the 
roots  of  the  nerves  supplying  the  affected  parts. 

After  the  pain  has  been  present  for  a  period  of  from  a  few  weeks  to  several 
months,  paralysis  with  muscular  atrophy,  resulting  from  pressure  upon  the 
anterior  nerve  roots,  appears.     In  consequence  of  the  location  of  the  lesion 


ACUTE    SPINAL    LEPTOMENINGITIS.  783 

the  arms  are  chiefly  affected,  they  become  weak,  and  atrophy,  resulting  in 
contractures  of  different  sets  of  muscles,  takes  place.  Sometimes  there  may 
be  areas  of  cutaneous  anaesthesia. 

Still  later,  if  the  growth  of  new  tissue  increases  further,  a  spastic  paralysis, 
due  to  interference  with  the  motor  tracts  of  the  cord,  occurs;  the  reflexes  are 
exaggerated;  there  is  no  atrophy  but  in  cases  of  long  standing  there  may  be 
anaesthesia,  rectal  and  vesical  paresis  and  a  tendency  to  the  development  of 
bed-sores.  While  the  course  of  the  disease  is  chronic  it  does  not  in  itself 
jeopardize  life  and  treatment  may  result  in  improvement. 

Treatment.  If  the  disease  is  of  syphilitic  origin  the  treatment  consists  in 
the  employment  of  usual  means  adapted  to  specific  disease.  The  pains  may 
be  relieved  by  antipjTrine,  acetphenetidine,  codeine,  etc.  Hydrotherapeutic 
measures  and  electricity  are  to  be  recommended,  together  with  the  applica- 
tion of  counterirritation,  especially  the  Paquelin  cautery,  to  the  back  of  the 
neck.  Where  the  condition  is  the  result  of  bone  disease,  tuberculous  or  other- 
wise, orthopaedic  or  other  surgical  treatment  is  indicated. 

Hcemorrhagic  pachymeningitis  is  very  rare  and  is  seldom  diagnosticated 
intra  vitam.  It  may  occur  at  any  level  of  the  cord,  its  symptoms  resemble 
those  described  above  and  it  frequently  co-exists  with  haematoma  of  the  cere- 
bral dura. 

ACUTE  SPINAL  LEPTOMENINGITIS. 

Acute  inflammations  of  the  pia  mater  of  the  cord,  aside  from  cerebrospinal 
meningitis  of  the  epidemic  type,  occur  as  the  result  of  tuberculous  infection, 
secondary  to  the  acute  infectious  diseases,  following  exposure  to  cold  or 
injury  and  from  the  extension  of  infections  of  the  cerebral  meninges. 

Pathology.  The  membrane  is  first  swollen  and  hyperaemic.  later  there  is 
exudation  of  serous  or  purulent  fluid  into  the  meshes  of  the  pia  and  the  arach- 
noid; these  membranes  are  infiltrated  with  round  cells  and  adhesions  and 
thickenings  result.  Secondary  changes  may  take  place  in  the  cord  and 
spinal  nerve  roots,  the  final  pathological  change  consisting  of  areas  of  scle- 
rosis in  these  tissues. 

Symptoms.  These  are,  at  the  onset,  those  of  acute  inflammatory  processes 
of  other  parts,  namely,  a  chill,  followed  by  rise  of  temperature,  headache, 
malaise  and  general  pains;  these  last  occur  especially  in  the  back  and  limbs 
and  are  increased  by  motion.  There  are  stiffness  and  muscular  rigidity 
of  the  spine  as  well  as  sensitiveness  of  the  spinal  nerves.  Kernig's  sign — ■ 
an  inability  of  the  patient,  when  the  thigh  is  flexed  at  a  right  angle  to  the  body, 
to  extend  the  leg  upon  the  thigh — is  present.  The  reflexes  are  often  increased, 
later,  however,  loss  of  reflexes  with  paralysis  occurs,  should  the  inflammation 
be  of  severe  type.     There  may  be  vesical  and  rectal  disturbances  and  trophic 


784  DISEASES    OF    THE    NERVOUS    SYSTEM. 

disorders  evidenced  by  blueness  or  pallor  of  the  skin  and  a  tendency  to  bed- 
sores may  appear. 

The  course  of  the  affection  varies;  death  may  supervene  within  from  a  few 
days  to  several  weeks,  due  to  involvement  of  the  cranial  nerves  by  reason  of 
extension  of  the  inflammation  to  their  foci  of  origin.  Complete  recovery 
may  take  place  in  mild  instances  while  after  attacks  of  severe  type  the  patient 
is  often  left  with  permanent  localized  motor,  sensory  or  trophic  lesions. 

Lumbar  puncture  reveals  the  presence  of  an  increased  quantity  of  cerebro- 
spinal fluid  which  escapes  in  drops  through  the  needle,  or  if  there  is  a  consider- 
able augmentation  in  its  amount,  the  fluid  will  spurt  forth  in  a  stream  of  more 
or  less  force.  Bacteriological  examination  of  the  fluid  may  show  the  cause 
of  the  lesion  and  by  cytological  examination  more  or  less  light  may  be  thrown 
upon  the  astiological  factor  of  the  inflammation.  If  meningitis  is  present  the 
fluid  is  rarely  clear  and  contains  no  sugar.  Tuberculous  fluid  is,  as  a  rule, 
quite  turbid;  in  acute  processes  the  number  of  leucocytes  is  likely  to  be  large 
and  chronic  meningitis  is  usually  evidenced  by  a  relative  increase  in  the 
number  of  mononuclear  lymphocytes.  Fresh  blood  is  usually  due  to  the 
puncture  while  decomposed  blood  may  be  found  following  injury  or  in  cases 
of   pachymeningitis. 

The  prognosis  is,  as  a  rme,  unfavorable,  especially  in  the  tuberculous  form. 
Instances  secondary  to  the  infectious  diseases  may  recover. 

Treatment.  This  consists  in  absolute  rest  in  bed  in  a  dark  room,  the 
employment  of  sedatives  and  of  the  other  therapeutic  means  discussed  under 
the  treatment  of  epidemic  cerebrospinal  meningitis  (p.  109). 

Chronic  spinal  leptomeningitis  may  result  from  the  continuation  of  an 
acute  process  particularly  epidemic  cerebrospinal  meningitis,  from  the  exten- 
sion of  chronic  cord  inflammations,  syphilitic  infection  and  chronic  alcoholism. 
When  this  condition  exists  the  membranes  become  thickened  and  opaque, 
adhesions  to  the  surface  of  the  cord  are  formed  and  the  cord  itself  under  these 
adhesions  may  be  the  seat  of  an  inflammatory  process  (meningomyelitis). 
The  walls  of  the  blood-vessels  are  thickened  and  in  cases  due  to  syphilis  gum- 
mata  may  be  found;  frequently  there  is  a  co-existent  chronic  inflammation 
of  the  cerebral  meninges. 

Symptoms.  These  are  not  well  marked  and  consequently  the  condition 
is  seldom  diagnosticated.  A  chronic  and  obstinate  stifi'ness  of  the  back  and 
limbs  is  the  principal  manifestation  and  with  this  are  cramp-like  pains,  sen- 
sory and  motor  disorders  and,  when  the  lower  segments  of  the  cord  are  affected, 
there  may  be  vesical  and  rectal  disturbances. 

Lumbar  puncture  reveals  an  increase  of  the  cerebrospinal  fluid. 

Treatment  consists  in  the  employment  of  every  possible  measure  to  main- 
tain the  patient's  general  health.  In  syphilitic  cases  appropriate  specific 
treatment  in  the  form  of  mercury  and  the  iodides  should  be  administered. 


HAEMORRHAGE    INTO    THE    SPIXAL    MEMBRANES.  785 

Warm  baths  should  be  taken  either  at  home  or  at  natural  springs.  These 
not  only  in  themselves  benefit  the  patient  but  are  an  important  adjunct  to 
the  antisyphilitic  treatment.  Counterirritation  by  means  of  the  Paquelin 
cautery  is  often  useful. 

HAEMORRHAGE  INTO  THE  SPINAL  MEMBRANES. 

Synonyms.     H£ematorrhachis;  Meningeal  Apoplexy. 

Spinal  meningeal  hsemorrhage  occurs  either  without  the  dura — extramen- 
ingeal — or  between  the  dura  and  the  pia — intrameningeal. 

The  former  condition,  as  a  rule,  is  due  to  injury — fracture,  gunshot-wound 
or  puncture — or  is  the  result  of  aneurysmal  rupture. 

Intra-meningeal  haemorrhage  is  not  often  seen  but  may  occur  in  malignant 
forms  of  the  infectious  diseases,  or  due  to  rupture  of  aneurysms  of  the  basilar 
or  vertebral  arteries.  It  has  been  observed  post  mortem  in  conditions 
associated  with  convulsions,  such  as  tetanus,  strychnine  poisoning  or  epilepsy. 

In  extradural  haemorrhage  the  blood  is  extravasated  from  the  veins  which 
surround  the  dura;  the  quantity  of  the  blood  varies  from  a  small  amount, 
forming  a  clot  which  covers  but  a  small  area,  to  a  quantity  sufficiently  extensive 
to  extend  the  entire  length  of  the  cord,  in  which  case  it  may  cause  a  consid- 
erable compression.     It  most  frequently  occurs  in  the  cervical  region. 

The  quantity  of  subdural  haemorrhage  is  also  variant.  The  clot  may  be 
so  small  as  to  extend  along  the  cord  for  an  inch  or  two  or  of  sufficient  size  to 
fill  the  entire  subarachnoid  space;  rarely  it  may  extend  into  the  ventricles 
of  the  brain. 

Symptoms.  These  may  be  wholly  absent  unless  the  haemorrhage  is  of 
sufficiently  large  amount  to  compress  the  cord.  In  this  case  they  vary  from 
hardly  recognizable  manifestations  to  those  of  marked  compression — sudden 
severe  pain  in  the  back  extending  to  the  lower  part  of  the  trunk  or  to  its 
ventral  surface,  muscular  twitchings  or  even  a  local  or  general  convulsion. 
Following  "these  symptoms  motor  and  sensory  paralyses  develop,  seldom, 
however,  are  these  complete.  The  symptoms  differ  with  the  location  of  the 
extravasation,  cervical  haemorrhage  being  evidenced  by  pain  or  anaesthesia  in 
the  neck  and  arms,  which  may  be  followed  by  paralyses  of  both  arms  and 
legs,  there  may  be  difficulty  in  respiration  and  deglutition  and  pupillary  dis- 
turbances. Dorsal  haemorrhage  is  accompanied  by  pain  in  the  back,  thorax 
and  abdomen,  followed,  it  may  be,  by  paraplegia,  the  reflexes  remaining 
normal.  In  haemorrhage  in  the  lumbar  region  the  pain  and  paralysis  affect 
the  legs,  the  reflexes  are  lost  and  there  are  vesical  and  rectal  disturbances. 

Death  may  occur  within  a  few  hours  if  the  haemorrhage  is  of  large  extent, 
while  small  clots  may  be  absorbed,  the  symptoms  disappearing  as  this  takes 
place;  in  other  cases  the  patient  lives  but  permanent  paralytic  condition? 
50 


786  DISEASES    OF    THE    NERVOUS    SYSTEM. 

remain.  Cervical  haemorrhage  is  most  serious  on  account  of  the  likelihood 
of  involvement  of  the  medulla. 

Treatment.  The  patient  should  be  kept  absolutely  at  rest  and  preferably 
upon  his  side  or  face  lest  the  blood  accumulate  along  the  posterior  columns 
of  the  cord;  the  bowels  should  be  kept  open  by  the  administration  of  fractional 
doses  of  calomel  and  the  milder  salines.  Counter-irritation  to  the  spinal 
region  by  means  of  leeches  or  dry  cups  may  be  employed  but  the  use  of  ice 
bags  is  preferable.  The  nervous  and  circulatory  excitation  may  be  controlled 
by  small  doses  of  the  bromides  (lo  grains — 0.66 — every  two  or  three  hours)  and 
aconite  tincture  (5  drops — 0.33 — every  two  hours)  until  the  desired  effect  has 
been  accomplished.  Later,  potassium  iodide  or  the  s^Tup  of  hydriodic  acid 
may  be  given  in  the  hope  of  facilitating  absorption  and  when  the  acute  stage 
has  passed  the  usual  means — massage,  electricity  and  hydrotherapeutic 
measures — calculated  to  bring  about  a  return  of  normal  muscular  and  nerv- 
ous tone,  may  be  employed. 

In  massive  hemorrhages  with  symptoms  of  marked  compression  operative 
intervention  with  a  view  to  the  alleviation  of  this  condition  may  become 
advisable. 

DISEASES  INVOLVING  CHIEFLY  THE  PERIPHERAL  NERVES. 

NEURITIS. 

Definition.  x\n  inflammatory  process  affecting  a  nerve.  The  inflamma- 
tion may  involve  one  nerve  {localized  neuritis)  or  many  {multiple  or  poly- 
neuritis). When  the  condition  affects  only  the  tissue  surrounding  the  nerve 
it  is  spoken  of  as  a  perineuritis,  inflammation  of  that  tissue  within  the  nerve 
which  encloses  the  bundles  of  nerve  fibres  is  termed  interstitial  neuritis,  while 
a  parenchymatous  neuritis  is  an  affection  of  the  nerve  fibres  themselves. 

.etiology.  Neuritis  may  be  caused  by  exposure  to  cold;  by  injuries  to  a 
nerve  trunk  from  contusions,  wounds  or  stretching,  such  as  may  occur  in 
fractures  or  dislocations;  by  pressure  from  aneurysm,  new  growth  or  the  con- 
stant use  of  a  crutch  or  tool;  by  extension  of  inflammation  of  adjoining  parts; 
by  the  poisons  of  acute  infectious  diseases,  typhoid  fever,  diphtheria,  etc.; 
by  gout,  purinaemic  conditions  and  s}^hilis.  It  also  occurs,  more  especially 
in  its  multiple  form,  as  a  result  of  alcoholism  and  of  chronic  metallic  poisoning, 
particularly  that  due  to  arsenic  and  lead  and  may  rarely  follow  long  con- 
tinued use  of  sulphonmethane  or  sulphonethylmethane. 

Pathology.  The  affected  nerve  is  first  red,  swollen  and  congested,  the 
perineurium  and  nerve  substance  are  likely  to  be  infiltrated  with  extrava- 
sated  white  blood  cells  and  there  may  be  an  increase  in  the  neuroglia  tissue. 
The  process  having  reached  this  stage  either  undergoes  resolution,  goes  on 


EASES    INVOLVING    CHIEFLY    THE    PERIPHERAL    NERVES.         787 

to  complete  destruction  of  the  nerve  or  the  increase  of  connective  tissue  con- 
tinues until  the  nerve  undergoes  atrophy  and  is  wholly  replaced  by  this  sub- 
stance. In  the  parenchymatous  variety,  the  employment  of  the  microscope 
reveals  a  swelling  and  opacity  of  the  myelin  substance  and  later  a  granular 
degeneration;  finally  the  myelin  and  the  axis  cylinder  degenerate,  only  the 
nerve  sheath  remaining,  this  later  becoming  converted  into  connective  tissue. 

Symptoms.  In  localized  neuritis  pain,  increased  on  motion,  and  tender- 
ness along  the  course  of  the  nerve  extending  even  to  its  termination,  are  the 
dominant  symptoms.  The  pain  is  usually  worst  at  the  site  of  the  inflamma- 
tory process  although  it  may  affect  the  distribution  of  the  nerve  as  well,  and 
more  rarely  the  entire  limb.  In  very  mild  instances  there  may  be  only  numb- 
ness and  tingling  but  in  those  of  severer  type  the  pain  is  apt  to  be  aching, 
burning  or  lancinating  in  character;  it  is  usually  worse  at  night.  Trophic 
changes  occur  such  as  oedema,  glossing  of  the  skin,  sweating,  increased  surface 
temperature  and  muscular  wasting.  Motor  disturbances,  such  as  spasmodic 
contractions  or  partial  paralysis,  are  not  infrequent. 

The  electric  reaction  may  be  unchanged  in  mild  types;  in  severer  instances 
the  response  to  electric  stimulus  is  slow  and  the  reaction  of  degeneration,  i.e., 
loss  of  faradic  excitability  in  both  muscle  and  nerve  and  of  galvanic  reaction 
in  the  nerve,  while  the  galvanic  excitability  of  the  muscle  is  changed  so  that 
the  cathodal  closure  contraction  is  less  than  or  about  equal  to  the  anodal 
closure  contraction,  is  observed;  the  cathodal  closure  contraction  is  greater 
in  the  normal  muscle  than  the  anodal  closure  contraction. 

The  course  of  the  disease  varies,  some  patients  recovering  within  a  few 
weeks,  while  others  continue  to  the  chronic  stage,  recovering  gradually  after 
months  of  disability;  instances  due  to  injury  or  cold  are  favorable  while  those 
resulting  from  the  extension  of  adjacent  inflammation  are  the  most  severe. 
When  recovery  is  imminent  the  reaction  of  the  nerve  to  galvanic  stimulation 
gradually  reappears. 

Symptoms  of  Neuritis  of  Special  Nerves.  Facial  neuritis  is  particularly 
likely  to  result  from  exposure  to  cold  and  is  accompanied  by  paralysis  of  the 
muscles  supplied  by  the  nerve.  Median  neuritis  is  evidenced  by  pain  and 
motor  symptoms  in  the  palmar  surface  of  the  thumb,  index  and  middle  fingers 
and  radial  side  of  the  ring  finger. 

In  ulnar  nerve  involvement  the  symptoms  are  confined  to  the  ulnar  side 
of  the  ring  finger  and  the  little  finger  with  atrophy  of  the  muscles  supplied  by 
this  nerve.  Musculo-spiral  neuritis  is  characterized  by  pain  affecting  the 
arm  and  forearm  with  motor  disturbances  in  the  muscles  supplied.  Wrist 
drop  may  occur  in  severe  cases.  In  neuritis  of  the  circumflex  nerve  the  motor 
and  sensory  disorders  are  confined  to  the  region  of  the  deltoid  and  teres  minor 
muscles. 

Inflammations  of  the  brachial  plexus  produce  a  combination  of  the  symp- 


788  DISEASES    OF    THE    NERVOUS    SYSTEM. 

toms  ascribed  above  to  affections  of  the  various  branches  of  this  structure, 
numbness  and  tinghng  in  the  arm,  pain  upon  axillary  pressure  and  upon 
raising  the  limb,  loss  of  muscular  power  and  trophic  disorders. 

Treatment.  This  consists  in  eradicating  the  cause,  if  possible,  in  relieving 
the  pain,  in  combating  the  inflammatory  process  and  in  assisting  the  regenera- 
tion of  the  diseased  nerves. 

When  the  condition  is  dependent  upon  constitutional  disorders,  such  as 
syphilis  or  purinsmia,  appropriate  treatment  should  be  employed;  inflamma- 
tions of  adjoining  structures  should  receive  attention,  fractures  and  disloca- 
tions should  be  reduced  and  causes  of  pressure  removed. 

The  importance  of  rest  cannot  be  over-estimated.  The  limb  may  be  put 
up  in  splints  or  sand  bags  may  be  applied  along  its  sides;  the  advantage  of 
the  latter  procedure  being  that  it  renders  the  employment  of  local  measures 
more  easy.  The  pain  may  be  controlled  by  various  local  applications  such 
as  compresses  of  10  to  20  percent,  ichthyol  ointment,  hot  compresses  or 
poultices  of  flaxseed,  or  ice  bags.  The  actual  cautery  is  useful,  its  applica- 
tion being  rendered  painless  by  means  of  the  ethyl  chloride  spray.  Rubbing 
with  counter-irritant  liniments,  such  as  that  composed  of  equal  parts  of  menthol, 
hydrated  chloral  and  camphor,  may  be  effectual.  In  cases  of  severe  pain 
the  administration  of  the  coal  tar  analgesics  is  indicated;  of  these  salipyrine 
(gr.  X — 0.66)  given  every  hour  until  relief  is  experienced  is  perhaps  the  best; 
acetphenetidine,  gr.  v  to  x  (0.33-0.66)  three  times  a  day,  acetanilide,  gr.  v 
(0.33)  every  four  hours  or  antipyrine,  gr.  x  (0.66)  three  times  a  day  may  be  em- 
ployed. If  there  is  any  tendency  to  heart  weakness  these  drugs  should  be  used 
with  caution  and  it  is  wise  oftentimes  to  add  a  grain  (0.065)  of  citrated  caffeine 
to  each  dose.  Codeine  or  morphine  in  small  doses  may  be  added  to  any  of 
the  above  drugs  if  their  analgesic  effect  is  insufficient.  Codeine  alone  may 
be  employed  (gr.  i-ii — 0.065  to  0.13)  and  when  the  pain  resists  all  less  potent 
remedies,  recourse  to  morphine  may  become  necessary.  This  drug  should 
be  given  hypodermatically  and  with  extreme  caution  since  the  liability  to 
establishment  of  the  habit  is  great.  Under  no  circumstances  should  the 
patient  be  allowed  to  use  the  syringe.  H}'podermatic  injections  of  cocaine 
hydrochloride,  gr.  ^  to  J  (0.008-0.022)  and  of  beta  eucaine  hydrochloride  in 
the  same  dosage  may  be  useful.  The  injection  should  be  given  at  the  seat 
of  the  pain. 

Potassium  (not  sodium)  salicylate  may  be  given  with  benefit  in  certain 
cases  and  massa  hydrargvri,  one  or  two  grains  (0.065-0.13)  daily  has  been 
recommended. 

When  the  acute  stage  of  the  inflammation  is  past  measures  should  be  taken 
to  bring  about  a  regeneration  in  the  affected  nerves.  Here  potassium  iodide 
may  at  times  be  found  useful  but  the  so-called  nerve  tonics — strychnine  in 
moderately  large  doses  (gr.  -^ — 0.002 — ^three  times  a  day)  either  alone  or  com- 


MULTIPLE    PERIPHER.\L    NEURITIS.  789 

bined  with  quinine  and  phosphorus,— are  more  usually  efficacious.  The 
tendency  to  atrophy  of  the  muscles  and  the  loss  of  nutrition  of  the  affected 
parts  indicate  the  employment  of  electricity,  massage,  hydrotherapeutic 
measires  and  passive  movements.  These,  however,  should  not  be  instituted 
while  tenderness  persists  or  if  they  seem  to  exhaust  the  diseased  parts.  Elec- 
tricity may  be  given,  in  proper  instances,  daily  but  for  not  more  than  a  few 
moments.  The  faradic  current  is  an  excellent  means  for  restoring  both 
sensation  and  motility,  but  it  should  never  be  given  strong  enough  to  cause 
discomfort.  The  interrupted  galvanic  current  is  indicated  if  there  is  no 
response  to  faradism,  but  the  latter  should  be  substituted  as  soon  as  regen- 
eration has  so  far  taken  place  as  to  bring  about  a  return  of  faradic  irritability. 
Warm  baths,  massage  and  movements  also  aid  in  restoring  the  normal  con- 
dition of  the  part  by  stimulating  the  circulation  and  thus  improving  the  dis- 
ordered state  of  the  nutrition. 

MULTIPLE  PERIPHERAL  NEURITIS. 

Synonym.     Polyneuritis. 

Definition.  An  inflammation  of  a  number  of  the  peripheral  nerves  at  the 
same  time. 

.Etiology.  Multiple  neuritis  may  result  from  the  introduction  into  the  body 
of  various  poisonous  substances;  of  these  the  mostcommon  is  alcohol;  other  exo- 
genous causes  are  lead,  "arsenic,  carbon  bisulphide  and  monoxide,  anilin,  cop- 
per, zinc,  mercury,  phosphorus,  ergot,  morphine,  aether,  sulphonmethane,  sul- 
phonethylmethane,  etc.  The  condition  may  occur  as  a  complication  of  the 
infectious  diseases  such  as  enteric  fever,  influenza,  diphtheria,  leprosy, 
measles,  sepsis,  etc.,  and  here  is  due  to  the  specific  toxin  of  the  infection. 

Beri-beri  is  a  particular  form  of  neuritis  and  is  probably  caused  by  a  specific 
organism. 

Poisons  formed  in  the  body  in  certain  constitutional  states,  e.  g.,  diabetes 
mellitus,  gout  and  purinaemic  conditions,  may  cause  neuritis  and,  finally,  it 
may  occur  in  the  chronic  wasting  diseases,  anaemia,  tuberculosis,  cancerous 
states  and  general  malnutrition.  The  disease,  except  the  form  which  is  a 
sequela  of  diphtheritic  infection,  and  that  occurring  with  anterior  poliomye- 
litis, is  one  of  adult  life  and  is  seen  most  commonly  between  the  ages  of  twenty 
and  fifty  years.  The  great  majority  of  cases  are  the  result  of  alcoholism  and 
women  seem  particularly  prone  to  this  type  of  neuritis.  Exposure  to  cold 
may  act  as  a  predisposing  factor. 

Pathology.  The  inflammation  is  usually  of  the  parenchymatous  type  and 
the  changes  in  the  nerve  substance  are  identical  with  those  described  on 
pages  786  and  787. 

Symptoms.     The  onset  of  the  disease  may  be  acute  or  subacute.     In  the 


790  DISEASES    OF    THE    NERVOUS    SYSTEM. 

acute  form  there  are  chilly  sensations  followed  by  a  moderate  rise  of  tempera- 
ture— 102°  to  104°  F.  (38.8°-4o°  C.) — with  general  pains,  malaise,  etc.  At 
times  the  onset  may  occur  without  febrile  movement. 

Sensory  symptoms  appear  early;  there  is  severe  pain  in  the  limbs,  increased 
by  movement  or  pressure;  there  is  tenderness  along  the  course  of  the  affected 
nerves  and  there  may  be  various  paraesthesise,  such  as  tingling,  numbness, 
sensations  of  cold  and  girdle  sensations  about  the  limbs  or  body.  Anaesthesia 
begins  at  the  fingers  or  toes  and  extends  symmetrically  up  the  limbs. 

Motor  Symptoms.  Following  the  disturbances  of  sensation  muscular 
weakness  appears  which  soon  may  develop  into  complete  paralysis  of  the 
limbs  so  that  the  patient  may  become  unable  to  move  in  bed;  the  extensors 
may  be  more  severely  affected  than  the  flexors  and  in  consequence,  wrist 
and  foot  drop  occur.  Atrophy  soon  appears  with  diminution  or  loss  of  the 
deep  reflexes.  There  may  be  ataxia,  evidenced  by  inability  to  perform  fine 
movements,  and  loss  of  muscular  sense.  There  are  no  vesical  or  rectal  dis- 
turbances. 

Trophic  Symptoms.  These  occur  as  a  result  of  vaso-motor  paralysis  and 
there  may  be  resulting  oedema,  glossiness  of  the  skin,  sweating,  skin  eruptions 
and  roughened  nails;  bed  sores  are  unlikely  to  develop. 

The  paralysis  often  does  not  affect  all  the  nerves  of  a  limb  but  is,  as  a  rule, 
symmetrical. 

The  cranial  nerves  are  at  times  affected  and,  as  a  result  of  their  involvement, 
there  may  be  facial  paralysis,  nystagmus  or  strabismus  and  disturbances 
of  heart  action  due  to  inflammation  of  the  vagus. 

Mental  disturbances  such  as  disorders  of  memory,  abnormalities  of  intel- 
lection and  a  mental  condition  known  as  Korsakoff's  disease,  characterized 
by  a  tendency  to  "pseudo-reminiscence"  and  to  tell  of  imaginary  adventures 
or  experiences,  may  occur. 

Alcoholic  neuritis  is  usually  rapid  in  onset  and  may  be  accompanied  by 
mental  symptoms  such  as  delirium  or  delusions;  the  pain  and  anaesthesia 
are  very  marked  and  the  paralysis  may  be  total.  In  other  patients  the  symp- 
toms may  be  almost  identical  with  those  of  locomotor  ataxia  (pseudo-tabes) 
but  there  is  no  pupillary  disturbance  and  rectal  and  vesical  control  remain 
normal. 

Lead  neuritis  may  be  ushered  in  by  intestinal  colic;  there  may  be  a  lack  of 
disturbance  of  sensation  but  the  usual  motor  symptoms  are  present. 

Arsenic  neuritis  is  characterized  by  gastro-intestinal  disturbances  followed 
by  paralysis,  ataxia,  numbness  and  atrophy,  and  but  slight  pain.  A  brownish 
pigmentation  of  the  skin,  chiefly  on  the  extensor  aspects  of  the  limbs,  is  typical. 

Carbon  monoxide  poisoning  causes  a  neuritis  evidenced  chiefly  by  sensory 
symptoms;  these  are  usually  slight  but  last  for  a  long  time. 

Diphtheritic  neuritis  is  accompanied  by  marked  paralysis  with  slight  sensory 


MULTIPLE    PERIPHERAL    NEURITIS.  79I 

disturbance;  ataxia  may  be  present  and  the  cranial  nerves  are  often  involved 
as  shown  by  ocular  paresis  and  difficulty  in  articulation  and  deglutition. 
Death  may  occur  as  a  result  of  involvement  of  the  phrenic  nerve. 

The  prognosis.  The  usual  course  of  the  disease  is  slow  but,  as  a  rule,  re- 
covery finally  takes  place  unless  the  nerves  have  been  so  profoundly  affected 
that  regeneration  is  impossible.  In  alcoholic  neuritis  the  symptoms  rapidly 
increase  in  severity  for  several  weeks,  remain  stationary  for  two  or  three 
months  and  gradually  subside,  recovery  ensuing  usually  within  a  year.  In 
lead  and  arsenic  neuritis  the  duration  of  the  condition  depends  upon  the 
amount  of  the  poison  in  the  system  and  the  rapidity  with  which  it  is  elimin- 
ated; recovery  usually  takes  place  in  from  four  to  six  months.  Diphtheritic 
neuritis  is  dangerous  only  on  account  of  the  possibility  of  involvement  of  the 
nerve  control  of  the  vital  functions;  failing  this  deplorable  condition,  recov- 
ery occurs  in  three  or  four  months  although,  at  times,  the  symptoms  extend 
over  a  much  longer  period. 

Either  the  sensory  or  the  motor  symptoms  may  begin  to  disappear  first 
but,  even  if  there  are  long  periods  during  which  there  is  no  improvement,  one 
should  not  despair;  recovery  is  possible  even  after  two  years  or  more. 

An  unpleasant  consequence  of  the  disease  is  a  tendency  to  contracture  and 
deformity  due  to  the  unopposed  action  of  unaffected  muscles. 

Treatment.  This  in  certain  measure  depends  upon  the  cause  of  the 
neuritis.  In  alcoholic  neuritis  the  use  of  this  substance  should  be  stopped;  in 
instances  due  to  plumbism  or  arsenical  poisoning  a  change  of  occupation  may 
be  necessary,  although  much  may  be  accomplished  in  the  way  of  prophylaxis 
of  the  former  type  by  insisting  upon  thorough  washing  of  the  hands  before 
eating,  by  the  drinking  of  sulphuric  acid  lemonade  made  by  adding  five  drops 
(0.33)  of  aromatic  sulphuric  acid  to  a  wineglass  (60.0)  of  water,  and  by  keep- 
ing the  bowels  freely  open  with  Epsom  salts.  The  elimination  of  these  poisons 
may  be  aided  by  the  administration  of  potassium  iodide,  15  to  30  grains 
(1.0-2.0)  two  or  three  times  a  day. 

During  the  acute  stage  of  the  disease  the  patient  should  be  kept  at  rest 
in  bed  and  his  food  should  be  nutritious  and  easily  digestible,  the  bowels 
should  be  kept  open  and  the  skin  and  kidneys  active.  The  salicylates  may 
be  useful  in  mild  cases  and  the  pain  may  be  controlled  by  the  use  of  the  various 
agents  mentioned  under  the  treatment  of  neuritis  in  general  (p.  788). 

Contractures  and  their  resulting  deformities  should  be  prevented  by  keeping 
the  limbs  in  proper  position  by  the  employment  of  bandages,  splints  or  sand 
bags  and  the  pressure  of  the  bed  clothing  should  not  be  allowed  to  increase 
any  tendency  to  foot  drop. 

Gouty  or  purinaemic  conditions  should  receive  appropriate  treatment  and 
in  aneemic  states  iron,  arsenic,  codliver  oil  and  other  tonics  are  useful. 

In  polyneuritis  following  the  infectious  diseases  it  is  important  that  the 


792  DISEASES    or    THE    NERVOUS    SYSTEM. 

patient  should  be  kept  in  bed  until  all  heart  weakness  is  past  and,  if  there  are 
manifest  signs  of  cardiac  disorder,  he  must  be  warned  against  any  sudden 
movement,  sitting  up  in  bed  or  excitement,  since  undue  strain  may  result 
fatally,  death  being  due  to  heart  failure.  Here  cardiac  stimulants  are  often 
indicated  as  well  as  the  ordinary  treatment  of  the  condition. 

After  the  acute  stage  is  past  phosphorus  and  strychnine  are  indicated; 
it  is  often  wise  to  alternate  the  latter  drug  with  arsenic  giving  the  strychnine 
in  doses  of  4V  of  a  grain  (0.0015)  three  times  a  day  for  a  week,  then  the 
arsenic — arsenic  trioxide  gr,  2^  (0.003) — f<^r  a  week,  and  so  on.  The  nutri- 
tion of  the  affected  muscles  and  nerves  now  should  be  improved  by  the 
employment  of  faradism,  a  rapidly  interrupted  current  being  used  upon  the 
nerves  and  one  slowly  interrupted  upon  the  muscles.  Galvanism  is  also 
useful  and  warm  baths  at  body  temperature  for  a  half  hour  several  times 
daily,  as  well  as  massage  and  passive  movements,  in  moderation,  should  be 
employed. 

Contractvures  and  deformities  resulting  from  multiple  neuritis  may  necessi- 
tate the  employment  of  orthopaedic  apparatus  or  of  surgical  measures  such  as 
tenotomy  or  tendon  transplantation. 

SCIATICA. 

This  condition  is  the  result  either  of  a  neuralgia  or  more  usually  an  inflam- 
mation of  the  sciatic  nerve  or  its  sheath. 

.Etiology.  Sciatica  occurs  as  a  rule  only  in  adults  and  is  most  often  observed 
between  the  ages  of  thirty  and  fifty  years,  although  it  appears  at  times  in  the 
third  decade  of  life  as  well  as  in  individuals  over  fifty.  It  affects  men  much  more 
often  than  women.  The  poisons  of  chronic  rheumatism,  gout  and,  more 
rarely,  of  syphilis,  seem  to  predispose  to  the  disease,  while  as  exciting  causes 
exposure  to  cold  and  wet  and  to  draughts,  particularly  after  exertion,  may 
be  mentioned.  Mechanical  pressure  upon  the  nerve  by  intra-pelvic  tumors 
and  accumulations  of  faeces,  and  inflammatory  foci  either  within  or  outside 
the  pelvis  may  cause  sciatica. 

Pathology.  The  morbid  anatomy  of  this  condition  is  identical  with  that 
described  in  connection  with  other  forms  of  neuritis. 

Symptoms.  Of  these  pain  in  the  posterior  part  of  the  thigh  is  the  most 
frequent.  This  pain  may  extend  upward  as  far  as  the  sciatic  notch  through 
which  the  nerve  emerges  from  the  pelvis,  and  along  the  course  of  the  nerve 
through  the  popliteal  space,  down  the  leg  behind  the  internal  malleolus  and 
upon  the  dorsum  of  the  foot.  The  pain  may  be  more  or  less  distinctly  local- 
ized in  the  course  of  the  nerve  and  throughout  this  extent  tenderness  may  be 
present;  pressure  over  the  sciatic  notch  is  almost  pathognomonic.  Positions 
of   the   leg  which  stretch  the  nerve,  particularly  flexion  of  the  thigh  on  the 


SCIATICA.  793 

pelvis  while  the  leg  is  extended  at  the  knee,  increase  the  pain.  In  character 
the  pain  is  like  that  of  inflammations  of  other  nerves  and  the  onset  of  this 
symptom  may  be  gradual  or  sudden.  The  reaction  of  degeneration  is 
seldom  observed  but  the  patellar  reflex  may  be  absent.  Vaso-motor  and 
trophic  manifestations  are  rare. 

The  prognosis.  The  course  of  the  disease  is  chronic  and  often  obstinate, 
yet  recovery  is  the  rule.     Life  is  not  endangered. 

Treatment.  Rectal  and  pelvic  examinations  often  throw  light  upon  the 
causation  of  the  condition  and,  in  such  instances  removal  of  the  cause  is  of 
course  indicated.  Defects  of  the  spinal  column  are  often  responsible  also  and 
here  relief  may  be  obtained  by  orthopaedic  treatment.  Gouty,  rheumatic  and 
syphilitic  instances  should  receive  treatment  appropriate  to  these  conditions. 
The  acuity  of  the  attack  should  be  treated  by  rest  in  bed  and  the  application 
of  a  Thomas  splint  extending  from  the  axilla  to  the  heel.  Numerous  local 
applications  are  recommended  most  of  them  counter-irritant.  Of  these  per- 
haps the  best  is  the  thermo-  or  electric  cautery;  it  should  be  applied  very  lightly 
so  that  a  minute  after  its  use  the  skin  shall  show  no  trace;  every  two  days 
is  often  enough  to  employ  this  agent.  Other  counter-irritants  have  a  field 
of  usefulness;  of  these  leeches,  flaxseed  poultices,  collodium  cantharidatum 
or  a  mixture  containing  i6  parts  of  strong  spirit  of  ammonia,  spirit  of  rose- 
mary 12  parts,  spirit  of  camphor  4  parts,  may  be  employed  as  a  vesicant 
over  the  painful  points;  cold  applications,  the  aether  or  ethyl  chloride  spray, 
bandaging  with  a  mixture  of  sulphur  and  menthol,  and  ichthyol  may  be 
prescribed. 

The  injection  of  various  substances  into  the  painful  area  or  into  the  sheath 
of  the  nerve  is  often  efi&cacious.  Strychnine  sulphate  or  nitrate,  gr.  ^V  - 
-jV  (o.ooi  to  0.003)  injected  into  the  buttocks  twice  a  day  is  an  excellent 
remedy.  The  dose  may  be  gradually  increased  to  gr.  j-q  (0.006)  but  tlie 
patient  must  be  carefully  watched  for  increased  muscular  excitability.  In 
injecting  drugs  into  the  nerve  it  is  best  to  induce  anaesthesia  by  a  cocaine  injec- 
tion (gr.  l-l — 0.008-0.016)  before  the  procedure.  The  intra-neural  injec- 
tion may  consist  of  sterile  water  or  chloroform. 

Acupuncture  is  a  drastic  method  of  treatment  but  may  afford  relief.  Its 
technique  consists  in  plunging  several  needles  into  the  painful  area  for  a 
depth  of  about  two  inches  and  allowing  them  to  remain  for  about  a  quarter 
of  an  hour. 

Of  internal  analgesics,  antip}Tine,  acetphenetidine,  salipyrine,  and  ace- 
tanilide  in  the  usual  doses  may  be  tried.  If  there  is  tendency  to  heart 
weakness  it  is  always  wise  to  add  to  each  dose  of  these  drugs  2  or  3  grains 
(0.13-0.2)  of  caffeine  sodiobenzoate.  Codeine  may  also  be  employed  and 
at  times  the  pains  may  be  so  severe  that  the  hypodermatic  administration  of 
morphine  becomes  absolutely  necessary;  it  should,  however,  be  given  only 


794  DISEASES    OF    THE    NERVOUS    SYSTEM. 

as  a  last  resort  on  account  of  the  ease  with  which  patients  become  habituated 
to  its  use. 

For  the  disease  itself  aconitine,  gr.  4-gro  (0.00015)  with  g^^^  of  a  grain  (0.00 1) 
of  strychnine  may  prove  effectual.  These  should  be  given  every  six  hours  at 
first,  but  the  intervals  should  be  gradually  shortened  until  by  the  fifth  day  of  the 
treatment  the  patient  is  receiving  them  every  two  hours.  He  must  be  care- 
fully watched  for  signs  of  heart  weakness  and  should  be  told  to  warn  the  phys- 
ician when  tingling  and  numbness  of  the  pharynx  are  noticed.  Gelsemium 
to  the  physiological  limit  may  also  be  employed.  Oil  of  turpentine  in  doses 
of  15  drops  (i.o)  tliree  times  a  day  with  oil  of  wintergreen  has  been  considered 
a  specific,  but  is  of  rather  doubtful  value. 

In  rheumatic  patients  sodium  or  potassium  saHcylate  should  be  given  to  the 
physiological  limit;  colchicum  may  act  favorably  also  and  should  likewise 
be  administered  to  the  limit  of  tolerance.  Ichthyol  internally  in  small  doses 
may  prove  beneficial,  and  blue  mass  in  doses  of  i  grain  (0.065)  twice  a  day 
has  been  recommended  in  cases  where  the  inflammation  is  acute.  If  all 
other  drugs  are  without  effect  potassium  iodide  may  be  given. 

Massage  and  electricity  may  prove  useful  in  chronic  instances  especially  if 
atrophy  is  present.  The  galvanic  current  should  be  used,  one  electrode  being 
applied  at  the  point  of  emergence  of  the  nerve  from  th^  pelvis  and  the  other 
moved  along  the  course  of  the  nerve. 

Spa  treatment  with  warm  or  mud  baths  often  acts  well  but  is  by  no  means 
certain  to  do  so. 

Nerve  stretching  may  be  employed  as  a  last  resort.  The  technique  consists 
in  laying  the  patient  upon  his  back  and  fixing  him  in  this  position,  the  operator, 
with  one  hand  upon  the  patient's  knee  so  that  this  joint  may  remain  extended, 
flexes  the  thigh  upon  the  pelvis.  Too  much  force  should  not  be  exerted.  The 
operation  of  dissecting  the  sheath  from  the  nerve  for  a  distance  of  a  few  inches 
has  been  employed.  These  two  last  procedures  are  calculated  to  break 
adhesions  between  the  nerve  and  its  sheath. 


DISEASES  OF  THE  CRANIAL  NERVES. 
DISEASES  OF  THE  FIRST  PAIR:  THE  OLFACTORY  NERVES. 

The  functions  of  the  olfactory  nerves  may  be  disordered  at  their  points  of 
origin,  at  any  point  in  their  course  through  the  cerebral  tissue,  in  their  trunks, 
in  the  bulb  or  in  their  terminal  distribution  in  the  mucous  membrane  lining 
the  nose. 

Pathology.  The  disturbances  may  be  the  result  of  brain  tumors  involving 
their  course,  of  congenital  abnormality,  or  atrophy.     Affections  at  the  distri- 


DISEASES    OF    THE    SECOND    PAIR:    THE    OPTIC    NERVES.  795 

bution  of  the  nerves  in  the  nasal  lining  occur  as  a  result  of  chronic  nasal  inflam- 
mations or  new  growths.  Hysterical  disorders  of  smell  are  often  observed 
and  changes  in  the  function  of  the  nerves  which  have  no  apparent  patholog- 
ical basis,  are  seen  after  head  injuries  and  epilepsy. 

Symptoms.  These  consist  of  disorders  of  the  sense  of  smell:  a.  Anosmia 
or  loss  of  the  sense  of  smell.  This  condition  is  caused  most  frequently  by 
aflfections  of  the  nerves  in  the  nasal  raucous  membrane  due  to  nasal  catarrh 
or  polypi;  it  occurs  also  in  lesions  of  the  olfactory  bulbs  or  tracts,  such  as  may 
result  from  injuries,  tumors,  inflammations,  or  atrophy  of  the  nerves,  such  as 
may  occur  in  tabes;  it  is  also  seen  in  lesions  or  congenital  defects  of  the  olfac- 
tory centers. 

h.  Hyperosmia  or  increased  acuity  of  smell.  This  is  chiefly  a  hysterical 
manifestation  occurring  most  often  in  nervous  women.  Patients  have  been 
observed  who  could  recognize  persons  by  their  odor  alone. 

c.  Parosmia  or  hallucinations  of  smell.  These  are  seen  in  the  insane 
and  in  epileptics,  the  epileptic  aura  in  which  a  distinctive  odor  is  perceived 
being  an  example.  This  disturbance  may  occur  also  as  a  result  of  cerebral 
tumor  or  injury.  The  patient  may  have  so  perverted  a  sense  of  smell  as  to 
consider  two  totally  different  odors  as  alike  or  attribute  an  odor  to  a  certain 
substance  entirely  different  from  its  actual  odor. 

In  testing  the  sense  of  smell  the  essential  oils  such  as  those  of  peppermint, 
anise,  cloves,  etc.,  are  used,  and  in  the  further  diagnosis  of  the  condition 
thorough  rhinological  examination  should  never  be  omitted. 

Treatment  consists  in  the  proper  management  of  the  intranasal  lesion  if 
such  is  present;  otherwise  little  can  be  done  and  the  normal  sense  of  smell 
is  seldom  restored. 

DISEASES  OF  THE  SECOND  PAIR:  THE  OPTIC  NERVES. 

The  disease  may  occur  in  the  optic  tract,  in  the  chiasm,  in  the  optic  nerve 
itself  or  in  the  retina.  Lesions  of  the  optic  nerves  may  be  caused  by  new 
growths,  hsemorrhages,  meningitis,  abscesses,  syphilitic  disease,  etc.  Dis- 
orders of  the  optic  tract  may  exist  independently  of  retinal  change  but  when 
of  long  standing,  atrophy  of  the  retina  may  occur  as  a  consequence.  Chias- 
mal lesions  may  be  caused  by  tumors  of  the  base,  hydrocephalus,  basilar 
meningitis  and  acromegaly.  Such  lesions  usually  involve  that  part  of  the 
chiasm  through  which  the  decussating  fibres  pass  and  result  in  blindness  of 
the  nasal  halves  of  the  retinae.  Lesions  affecting  the  direct  fibres  of  one  side 
produce  blindness  in  one  eye  and  of  the  nasal  half  of  the  retina  of  the  other. 
Involvement  of  the  entire  chiasm  causes  total  loss  of  vision. 

Lesions  of  one  tract,  for  instance,  the  left,  cause  blindness  of  the  temporal 
half  of  the  left  retina  and  of  the  nasal  half  of  the  right,  a  condition  termed 


796  DISEASES    OF    THE    NERVOUS    SYSTEM. 

homonymous  hemianopsia.  The  hemianopsia  may  be  partial  or  entire,  depend- 
ing upon  the  extent  of  tlie  lesion,  and  the  vision  of  the  other  halves  of  each  retina 
may  or  may  not  be  impaired.  Disturbances  of  the  tract  anterior  to  the 
anterior  corpora  quadrigemina  often  involve  other  cranial  nerves  and  result 
in  optic  paralyses,  sensory  disorders  in  the  face  or  affect  the  special  senses. 
In  determining  the  site  of  the  lesion  in  hemianopia  Wernicke's  test  is  of  much 
value.  This  is  based  upon  the  assumption  that  the  pupillary  reflex  centers 
are  situated  in  or  anterior  to  the  anterior  corpora  quadrigerhina.  If  the 
lesion  is  behind  this  situation  the  pupil  will  contract  when  light  is  thrown 
upon  the  blind  portion  of  the  retina.  If  the  pupil  does  respond  to  light  it  is 
probable  that  the  lesion  is  a  central  one.  In  affections  of  the  optic  thalamus 
or  internal  capsule  hemiplegia  or  hemianaesthesia  are  likely  to  accompany 
the  ocular  disturbance;  lesions  of  the  right  motor  tract,  for  instance  with  left 
hemiplegia,  being  associated  with,  when  there  is  involvement  of  the  optic 
tract  in  the  internal  capsule,  disturbance  of  sight  characterized  by  inability 
to  see  objects  in  the  left  field  of  vision.  Conditions  of  mind  blindness — ability 
to  see  objects  but  failure  to  recognize  them — and  of  aphasia  may  also  occur. 

There  are  two  principal  lesions  of  the  optic  nerve,  these  are  optic  neuritis 
and  optic  atrophy. 

Optic  neuritis,  papillitis  or  choked  disk  begins  as  a  blurring  of  the  edges 
and  congestion  and  swelling  of  the  optic  disk,  later  the  margin  of  the  disk 
becomes  indistinguishable,  the  change  taking  place  first  upon  its  nasal  side. 
Indirect  examination  reveals  a  disk  red  or  reddish  gray  in  color,  while  direct 
inspection  shows  a  striated  appearance,  the  striae  radiating  from  the  center 
outward.  The  veins  are  dilated  while  the  arteries  remain  normal  in  size  or 
are  diminished.  The  retina  also  may  become  affected,  a  neuro-retinitis 
resulting.     Haemorrhages  may  take  place. 

The  condition  is  most  usually  the  result  of  some  intra-cranial  lesion,  partic- 
ularly tumor.  It  also  occurs  in  abscess,  meningitis,  nephritis,  anaemia, 
multiple  sclerosis  and  plumbism  and  idiopathically. 

The  milder  types  of  the  disease  may  cause  no  disturbance  of  sight,  in  severer 
cases  the  visual  function  is  impaired  and  may  be  wholly  lost.  If  the  inflam- 
mation subsides  the  symptoms  usually  become  less  marked,  but  the  condi- 
tion may  result  in  permanent  blindness. 

Optic  atrophy  occurs  primarily  in  an  hereditary  type,  appearing  in  the 
males  of  a  family  after  puberty;  it  occurs  also  in  spinal  diseases,  particularly 
locomotor  ataxia,  in  diabetic  disease,  plumbism  and  alcoholism,  after  exposure, 
and  in  the  acute  infectious  diseases. 

It  develops  secondarily  in  multiple  sclerosis  and  other  brain  diseases  and 
as  a  consequence  of  optic  neuritis. 

In  the  primary  tvpe  ophthalmoscopic  examination  reveals  a  grayish  disk 
of  well-defined  outline  and  a  practically  normal  condition  of  the  arteries,  while 


DISEASES    OF    THE    SECOND    PAIR:    THE    OPTIC    NERVES.  797 

in  the  secondary  form  the  disk  is  whitish  and  opaque,  its  margin  is  irregular 
and  the  arteries  are  shrunken. 

The  vision  is  disturbed  in  a  degree  varying  with  the  severity  of  the  lesion, 
it  becomes  less  acute,  the  field  of  vision  is  diminished  and  color  sense  is  changed. 
In  the  primary  type  blindness  usually  results;  in  mild  instances  of  the  secondary 
variety  recovery  may  occur  but  more  often  the  sight  is  permanently  impaired. 

The  treatment  is  that  of  the  cause  of  the  condition. 

Lesions  of  the  retina  may  be  either  organic  or  functional.  Of  the  former 
type  two  varieties  should  be  described. 

Hemorrhage  into  the  retina  occurs  in  nephritis,  in  chronic  gouty  condi- 
tions, syphilis,  septicemia,  anaemia,  leucaemia  and  purpura  haemorrhagica. 
The  extravasations  of  blood  take  place  in  the  nerve  fibre  layer  and  are  of 
greater  or  less  extent  and  pial  haemorrhages  may  co-exist.  The  haemorrhagic 
spot  is  at  first  bright  red,  then  darker,  and  finally,  as  the  blood  pigment  becomes 
absorbed,  light  in  color;  white  areas  may  be  visible,  due  to  exudates,  spots  of 
fatty  degeneration  or  consequent  sclerosis  and,  in  the  haemorrhages  of  septic- 
aemia, to  collections  of  white  blood  cells. 

Retinitis  occurs  in  malarial  states,  plumbism  and  in  the  same  conditions 
as  does  retinal  haemorrhage.  The  most  important  type  is  that  occurring  in 
chronic  nephritis.  The  ophthalmoscopic  appearance  is  characterized  by 
white  areas  differing  in  size  and  distribution.  These  are  the  result  of  haemor- 
rhages and  sclerotic  processes.  Arteriosclerosis  is  always  seen  in  patients 
exhibiting  this  affection.     According  to  Cowers  three  forms  are  distinguishable. 

a.  The  degenerative  with  retinal  changes  but  with  little  alteration  of  the 
disk.     This  is  the  most  common  type. 

b.  The  inflammatory  with  marked  sweUing  of  the  retina  and  obscuration 
of  the  disk. 

c.  The  haemorrhagic  with  numerous  haemorrhages  and  only  slight  inflam- 
mation. 

At  times  the  inflammatory  changes  in  the  optic  nerve  are  more  marked 
than  those  in  the  retina  which  may  cause  doubt  as  to  whether  the  lesion  is 
the  result  of  renal  or  intra-cranial  disease. 

Syphilitic  retinitis  is  rare;  when  congenital  it  usually  occurs  in  pigmentary 
form  {retinitis  pigmentosa). 

Ancemic  retinitis  occurs  especially  in  the  pernicious  type  of  the  disease. 
Sudden  blindness  in  one  or  both  eyes  may  take  place  after  profuse  haemor- 
rhage or  the  process  may  take  several  days  for  its  completion.  The  loss  of 
sight  may  prove  permanent.     Neuro-retinitis  may  also  occur. 

Chronic  malaria  with  consequent  anaemia  may  be  complicated  by  retinitis. 

Leucaemic  retinitis  is  characterized  by  an  enlarged  and  distended  condition 
of  the  retinal  veins,  there  may  be  haemorrhage  and  yellowish  or  white  spots. 

Functional  retinal  disturbance  or  amaurosis  occurs  as  a  result  of  a  variety 


798  DISEASES   OF   THE    NERVOUS    SYSTEM. 

of  causes.  Of  these  uramic  poisoning  is  the  most  frequent.  It  may  appear 
independently  of  other  uraemic  symptoms  or  before  or  after  convulsions  due 
to  the  same  cause.  Its  onset  is  usually  sudden  and  the  blindness  lasts  but  a 
few  days.  The  ophthalmoscopic  appearance  is  unchanged.  Analogous 
to  uraemic  amaurosis  are  the  types  of  this  condition  due  to  quinine,  plumbism, 
alcohohsm,  and  especially  to  methyl  alcohol  poisoning. 

Tobacco  amaurosis  affects  the  center  of  the  visual  field  particularly  and  is 
usually  of  gradual  development.  The  fundus  may  remain  normal  in  appear- 
ance or  there  may  be  congestion  of  the  disks.  Unless  the  use  of  the  drug  is 
discontinued  organic  changes  and  atrophy  of  the  disk  may  result.  A  central 
scotoma  for  red  and  green  is  always  present. 

Hysterical  amaurosis  may  occur  but  there  is  more  often  impairment  of 
vision  only;  the  blindness  may  affect  one  eye  only.  In  night  blindness  or  nyc- 
talopia vision  is  clear  by  day  or  strong  artificial  light  while  the  reverse  is  true 
in  the  shade  or  in  twilight.  In  hemeralopia,  the  opposite  condition  obtains. 
These  are  rare  states  and  may  occur  epidemically. 

Retinal  hypercBsthesia  is  not  often  observed  in  retinal  lesions  but  may  occur 
in  hysterical  patients. 

DISEASES   OF   THE   MOTOR   NERVES  OF  THE  EYEBALL:  THE 
THIRD,  FOURTH  AND  SIXTH  PAIRS. 

The  third  nerve,  the  oculomotor,  supplies  the  levator  palpebral  superioris, 
the  superior  and  inferior  recti,  the  internal  rectus,  the  inferior  oblique,  the 
sphincter  of  the  iris  and  the  ciliary  muscle;  the  fourth  nerve,  the  trochlear, 
the  superior  oblique,  and  the  sixth  nerve,  the  abducens,  the  external  rectus. 

Paralyses  or  spasms  of  the  third  nerve  occur  as  a  result  of  inflammation 
of  the  nerve,  as  a  result  of  pressure  from  the  products  of  neighboring 
inflammation — as  in  meningitis — from  tumors,  syphilitic  and  otherwise,  and 
due  to  lesions  at  the  origin  of  the  nerve  upon  the  floor  of  the  aqueduct  of 
Sylvius.  In  the  latter  case  there  is  accompanying  disturbance  of  the  other 
motor  nerves  of  the  eye.  Paralysis  of  this  nerve  occurs  also  in  rheumatic 
conditions,  secondary  to  the  infectious  diseases,  especially  diphtheria,  after 
exposure  to  cold,  in  hysteric  conditions  and  in  locomotor  ataxia.  Its  symp- 
toms are  ptosis,  pupillary  dilatation  and  entire  loss  of  accommodation,  double 
vision  and  divergent  strabismus. 

Cycloplegia  is  a  result  of  paralysis  of  the  ciliary  muscle  and  gives  rise  to 
loss  of  the  power  of  accommodation.  Objects  at  a  distance  are  seen  clearly 
while  those  nearby  are  indistinct.  When  in  both  eyes  it  is  usually  due  to 
lesion  at  the  origin  of  the  nerve.  It  is  seen  early  in  diphtheritic  paralysis 
and  occurs  also  in  locomotor  ataxia.     It  may  be  corrected  by  glasses. 

Iridoplegia  or  paralysis  of  the  iris  occurs  in  locomotor  ataxia,  brain  tumors, 


DISEASES  OF  THE  MOTOR  NERVES  OF  THE  EYEBALL.      799 

etc.  In  the  accommodative  form  the  pupil  does  not  alter  in  size  during  accom- 
modation. In  the  reflex  variety — the  "  Argyll- Robertson  pupil " — the  loss  of 
accommodation  to  light  may  be  tested  by  directing  the  patient  to  look  at  a 
distant  object,  then  a  bright  light  is  suddenly  flashed  into  the  eye.  If  this 
aifection  is  present  the  pupil  will  fail  to  contract.  In  skin  iridoplegia  the 
cutaneous  reflex  is  lost  and  a  reflex  dilatation  of  the  pupil  takes  place  if  the 
skin  of  the  neck,  which  is  supplied  by  the  cervical  sympathetic  nerve,  is  irri- 
tated mechanically  or  electrically. 

The  condition  of  anisocoria,  unequal  pupils,  may  be  observed  in  health 
and  also  as  a  symptom*  of  locomotor  ataxia  and  paresis. 

Spasmodic  contraction  of  the  muscles  supplied  by  the  third  nerve  may  occur 
in  migraine,  hysteria,  meningitis,  congenital  and  other  cerebral  lesions  and 
in  albinos.  The  spasm  usually  is  in  the  form  of  a  rhythmic  movement  of 
the  eyeball  from  side  to  side — nystagmus — more  rarely  is  the  motion  rotary 
or  vertical. 

The  fourth  nerve,  the  trochlear,  is  subject  to  abnormal  conditions  analogous 
to  those  described  above  and  under  the  same  conditions.  Paralysis  of  this 
structure  is  manifested  by  loss  of  power  in  the  superior  oblique 
muscle  and  consequent  convergent  strabismus.  Here  there  is  impairment 
of  ability  to  move  the  eyeball  downward  and  inward.  This  defect  is  frequently 
not  noticeable.  The  head  is  inclined  forward  and  toward  the  unafiected 
side  and  diplopia  is  present  when  the  vision  is  directed  downward. 

The  sixth  nerve,  the  abducens,  may  be  paralyzed  as  a  result  of  lesions  similar 
to  those  affecting  the  third  and  fourth  nerves.  The  paralysis  produces  internal 
strabismus  since  the  only  muscle  supplied  by  this  nerve  is  the  external  rectus. 
The  eyeball  cannot  be  turned  so  as  to  look  outward.  Double  vision  may  be 
present  when  the  patient  looks  toward  the  paralyzed  side.  In  affections  of  the 
nucleus  of  origin  of  this  nerve,  conjugate  deviation  of  both  eyes  away  from  the 
side  of  the  lesion,  is  observed  due  to  the  fact  that  the  nucleus  of  the  third 
nerve  is  connected  with  that  of  the  sixth,  consequently  in  lesions  of  the  latter 
the  internal  rectus  is  paralyzed  in  associated  movements,  although  the  nucleus 
of  the  third  nerve,  which  suppHes  this  muscle,  is  not  affected;  there  is  no  dis- 
turbance of  the  power  of  convergence. 

General  paralysis  of  all  the  motor  nerves  of  the  eye  or  ophthalmoplegia 
may  be  caused  by  disease  of  the  nuclei  of  origin  of  the  third,  fourth,  and  fifth 
nerves,  by  tumors  and  the  pressure  of  inflammatory  exudates,  and  may  occur 
in  general  paresis,  locomotor  ataxia  and  progressive  muscular  atrophy.  It 
occurs  in  two  forms,  ophthalmoplegia  externa  and  ophthalmoplegia  interna. 
The  two  types  may  co-exist — total  ophthalmoplegia.  In  the  external  type 
the  eyeball  is  immobile,  ptosis  is  present  and  there  may  be  slight  exophthal- 
mos; with  it  there  may  be  optic  nerve  atrophy  and  involvement  of  other 
cranial  nerves. 


8oO  DISEASES    OF    THE    NERVOUS    SYSTEM. 

In  the  internal  type  power  of  accommodation  and  pupillary  reaction  are 
lost.  Ophthalmoplegia  is  usually  a  chronic  condition  but  rarely  an  acute 
form  is  observed,  the  onset  of  which  may  be  rapid;  accompanying  this  type 
are  cerebral  disturbance  and  haemorrhagic  degeneration  of  the  nuclei  of 
origin  of  the  motor  nerves  of  the  eyeball. 

Treatment  of  the  ocular  palsies.  This,  to  a  great  extent,  depends  upon 
the  cause.  In  acute  instances  the  pain  may  be  relieved  by  hot  compresses,  mild 
counter-irritation  and  the  application  of  leeches  to  the  temples.  Syphilitic 
instances  and  those  occurring  in  the  course  of  locomotor  ataxia  should  receive 
mercury  and  potassium  iodide  in  large  doses.  Strychnine,  hypodermatically 
in  considerable  doses,  -j^  to  o-V  of  a  grain  (0.002-0.003),  arsenic  and  iron 
are  also  useful;  the  three  may  be  given  in  combination.  In  the  chronic  type 
the  use  of  electricity  is  recommended.  If  galvanism  is  employed  the  anode 
is  applied  to  the  forehead  and  the  cathode  is  moved  along  the  margin  of  the 
orbit  over  the  affected  muscles;  if  the  faradic  current  is  used  the  cathode 
is  not  moved.  For  the  ptosis  the  current  is  applied  over  the  third  nerve. 
Double  vision  may  be  relieved  by  the  use  of  prisms,  or  if  it  is  impossible 
of  correction,  both  it  and  the  dizziness  may  be  obviated  by  wearing  an  opaque 
glass  over  the  affected  eve. 


DISEASES  OF  THE  FIFTH  PAIR:  THE  TRIGEMINAL  NERVES. 

Lesions  of  the  fifth  nerve  result  from  disease  of  the  pons,  especially  haemor- 
rhage or  sclerosis;  injury  or  disease  at  the  base  of  the  cranium,  such  as  bone 
caries,  meningitis,  syphilitic  or  other  new  growths;  pressure  upon  the  branches 
of  the  nerve  from  tumors  or  aneurysms  in  the  cavernous  sinus  or  from  lesions 
in  the  spheno-maxillary  fossa.     Primary  inflammation  of  the  nerve  is  rare. 

Sensory  symptoms  may  be  caused  by  hysteria  and  disturbances  of  taste 
by  the  influence  of  disturbances  of  the  facial  nerve  upon  the  chorda  tympani. 

Motor  disturbances.  These  consist  of  paralysis  and  spasm.  The  former 
involves  the  temporal,  masseter  and  pterygoid  muscles  and  is  characterized 
by  difficulty  in  mastication;  if  both  sides  are  involved  this  act  is  impossible 
and  the  lower  jaw  hangs  down.  If  only  one  side  is  affected  the  jaw  is  displaced 
toward  the  affected  side  when  open. 

Spasm  occurs  with  muscular  cramp,  in  tetanus  (lockjaw  or  trismus),  in 
tetany,  and  in  meningitis.  It  is  seen  also  in  hysteriaandasaresult  of  diseases 
of  the  mouth,  jaw  or  teeth.  The  jaws  are  tightly  shut  and  the  contraction 
of  the  muscles  of  chewing  may  be  painful.  Clonic  spasm  (chattering  teeth) 
may  occur  in  chorea,  hysteria  and  without  assignable  cause. 

Disturbances  of  taste  resulting  from  lesions  of  the  fifth  nerve  consist  in  the 
partial  or  complete  loss  of  this  sense  over  the  anterior  two-thirds  of  the  tongue 


DISEASES    OF    THE    SEVENTH    PAIR:    THE    FACIAL    NERVES.  8oi 

as  Stated  by  some,  although  it  would  seem  from  the  fact  that  many  trigeminal 
neurectomies  do  not  result  in  gustatory  disturbance  that  the  nerve  fibres  from 
this  part  of  the  tongue  may  reach  the  brain  by  more  than  one  route. 

Sensory  disorders  are  characterized  by  loss  of  sensation  of  half  the  face, 
conjunctiva,  cornea,  mucous  membrane  of  the  lips,  tongue,  hard  palate  and 
nose  of  the  same  side.  Smell  is  rendered  less  acute  as  a  result  of  drying  of 
the  nasal  mucous  membrane;  taste  may  be  disturbed.  Painful  tingling  may 
precede  the  anaesthesia.  Trophic  disturbances  occur  such  as  diminution  of 
the  saliva,  the  lachrymal,  buccal  and  nasal  secretions  and  the  teeth  may  become 
loose.  Herpes  with  pain  may  develop  over  the  course  of  the  nerve  and  there 
may  be  facial  oedema.  The  diagnosis  is  simple.  Taste  may  be  tested  by 
touching  the  tongue  on  either  side  with  a  weak  acid  solution  and  comparing 
the  effect,  motility,  by  directing  the  patient  to  bite  a  piece  of  soft  wood,  and 
sensation,  by  the  usual  methods. 

Treatment  should  be  directed  to  the  removal  of  the  causative  factor.  Syphil- 
itic cases  should  receive  appropriate  treatment.  The  teeth  should  be  put  in 
proper  order,  nasal  and  aural  examinations  should  be  made  and  any  existing 
abnormality  corrected.  Anaesthetic  parts  should  be  protected  against  injury 
and  irritation.  The  pain  may  be  relieved  by  the  means  described  under  the 
section  on  the  treatment  of  neuritis  (p.  788)  and  the  local  applications  there 
mentioned  are  also  useful.  Morphine  should  be  employed  as  a  last  resort 
only. 

The  use  of  the  faradic  current  and  of  massage  is  indicated  in  order  to  restore 
the  muscular  tone,  and  attention  should  be  given  to  the  general  health  of  the 
patient. 

DISEASES  OF  THE  SEVENTH  PAIR:  THE  FACIAL  NERVES. 

Disease  of  the  facial  nerve  may  result  in  paralysis  or  spasm. 

Paralysis  (Bell's  palsy,  monoplegia  facialis  or  mimetic  facial  paralysis) 
may  be  caused  by  lesions  in  the  cortex,  in  the  brain  between  the  cortex  and 
the  nucleus  of  origin  of  the  nerve,  in  this  nucleus  and  in  the  nerve  itself.  The 
cortial  lesions  occur  with  hemiplegia  due  to  cerebral  haemorrhage,  inflam- 
mations and  tumors;  those  of  the  nucleus  result  from  like  causes  and  from 
the  toxins  of  infectious  diseases,  especially  diphtheria,  and  lesions  of  the  nerve 
itself  may  be  caused  by  exposure,  extension  of  middle  ear  or  temporal  bone 
disease,  new  growths,  injury  at  the  base  of  the  brain,  meningitis  or  syphilitic 
infiltration  in  the  same  situation.  The  nerve  may  be  afi'ected  in  lesions  of 
the  medulla  oblongata,  and  as  a  result  of  traumatism  during  birth. 

Symptoms.  These  differ  with  the  site  of  the  lesion  causing  the  paralysis. 
The  onset  of  the  condition  is  usually  sudden  but  at  times  prodromal  symp- 
toms, such  as  disorders  of  taste,  facial  and  aural  pain  and  tinnitus,  are  noticed. 
51 


8o2  DISEASES    OF    THE    NERVOUS    SYSTEM. 

As  a  rule  the  paralysis  is  one-sided,  rarely  is  it  bilateral.  The  face  is  drawn 
toward  the  sound  side,  except  after  contracture,  in  cases  of  long  standing. 
The  affected  side  of  the  face  is  immobile  and  smooth,  the  forehead  loses  its 
wrinkles,  the  facial  expression  is  lost,  the  eye  remains  open  even  during  sleep, 
the  corner  of  the  mouth  drops  and  there  is  dribbling  of  saliva,  whistling  is  im- 
possible and  the  labials  are  pronounced  with  difficulty;  the  tongue  is  not  de- 
viated and  during  mastication  the  food  collects  in  the  paralyzed  cheek.  The 
corneal  reflexes  are  lost,  the  eye  waters  and  conjunctivitis  is  frequent.  Winking 
is  impossible  if  the  paralysis  is  complete.  In  peripheral  pa  ralysis  the  eye  may 
roll  upward  and  outward  (Bordier-Frankel's  sign)  Drinking  is  diflScult  on 
account  of  the  inability  of  the  patient  to  approximate  his  lips  to  the  glass. 

In  lesions  of  the  nerve  between  its  union  with  the  chorda  tympani  and  the 
geniculate  ganglion,  taste  is  lost  in  the  anterior  two-thirds  of  the  tongue  on  the 
affected  side.  The  saliva  is  diminished  and  the  tactile  sense  of  the  tongue 
may  be  impaired.  Auditory  disturbance  may  occur  due  to  concurrent  aural 
lesions  but  the  hearing,  especially  for  low  notes,  may  be  rendered  more  acute 
by  paralysis  of  the  stapedius  muscle.     Herpes  may  be  present. 

The  electric  reaction  in  mild  instances  may  remain  normal  in  the  paralyzed 
muscles,  and  here  recovery  within  a  few  weeks  is  usual.  In  more  severe  instances 
the  electric  reaction  in  the  nerves  is  diminished  while  in  the  nerves,  after  a 
few  weeks,  the  reaction  to  direct  galvanic  stimulation  is  increased,  the  anodal 
closure  contraction  exceeding  the  cathodal,  and  the  response  to  stimulation 
is  delayed.  Here  recovery  is  less  rapid  but  is  likely  to  be  complete  in  a  month 
or  two.  In  very  marked  instances  complete  reaction  of  degeneration  is  present, 
the  course  of  the  disease  is  much  more  protracted  and  may  last  for  a  year  or 
more.  Relapses  may  occur.  When  brain  tumor  or  necrosis  of  the  petrous 
portion  of  the  temporal  bone  are  aetiological  factors  the  paralysis  may  be 
permanent. 

Treatment  should  be  directed  at  the  cause  of  the  condition.  In  syphilitic 
cases  the  administration  of  the  iodides  in  gradually  increasing  doses  is  indi- 
cated. If  the  paralysis  is  due  to  lesions  of  the  middle  ear  these  should  receive 
appropriate  treatment.  When  pressure  is  responsible  its  cause  should  be 
removed  if  possible.  When  the  disease  is  the  result  of  exposure  the  salicylates 
in  large  doses  should  be  given  and  warm  compresses,  wet  or  dry,  should  be 
applied  to  the  face;  later  counter-irritation  by  means  of  the  thermo- cautery 
or  vesicants  is  useful.  The  hv-podermatic  exhibition  of  strychnine  sulphate 
in  doses  of  3^  to  -^o  of  a  grain  (0.002-0.003)  daily  or  every  two  days  may 
prove  useful  and  salicln,  20  to  30  grains  (1.3-2.0)  three  times  a  day  or  sodium 
salicylate  in  similar  dosage  may  be  prescribed  with  benefit.  In  the  later 
stages  electricity  should  be  employed;  galvanism  is  to  be  preferred;  the  current 
should  not  be  strong  and  it  may  be  applied  over  the  affected  muscles  and  also 
administered  by  placing  the  poles  alternately  below  and  in  front  of  the  ear, 


DISEASES    OF    THE    SEVENTH    PAIR:    THE    FACIAL    NERVES.  803 

and  interrupting  the  current  about  every  fifteen  or  twenty  seconds.  Massage 
of  the  facial  muscles  may  also  be  employed. 

Nerve  anastomosis  is  indicated  in  patents  in  whom  the  continuity  of  the 
nerve  has  been  destroyed  by  injury  or  by  disease,  after  electricity  has  been 
faithfully  used  for  several  months  without  sign  of  return  of  function.  The 
anastomosis  is  made  with  the  hypoglossal  or  the  spinal  accessory  nerve  and 
while  complete  recovery  may  not  take  place,  the  operation  is  likely  to  restore 
the  power  of  the  affected  muscles  to  a  considerable  extent  and  to  greatly 
mitigate  the  deformity. 

Spasm.  Facial  spasm,  mimic  spasm  or  convulsive  tic,  may  be  unilateral 
or  bilateral  and  consists  of  a  clonic  contraction  of  one  or  more  of  the  muscles 
innervated  by  the  seventh  nerve.  Habit  spasm  is  an  analogous  affection, 
occurring  usually  in  children  as  a  result  of  "making  faces." 

The  cause  is  indefinite,  but  the  condition  has  been  considered  as  due  to 
exposure,  to  pressure  at  the  base  of  the  brain  from  tumor  or  aneurysm  or  to 
a  lesion  of  the  facial  center  in  the  cerebral  cortex.  Reflex  instances  also  occur 
due  to  decayed  teeth,  intestinal  worms  or  sexual  disorders.  The  condition 
usually  involves  only  one  or  two  branches  of  the  nerve,  especially  those  supply- 
ing the  orbicularis  muscle  (blepharospasm)  and  the  neighboring  muscles. 
Here  there  is  twitching  of  the  eyelid  often  with  accompanying  spasm  of  the 
muscles  of  the  side  of  the  face.  The  angle  of  the  mouth  may  be  twitched 
downward  and  the  contractions  may  also  involve  the  muscles  of  mastication, 
the  tongue  and  the  platysma.  The  spasms  occur  spontaneously,  are  not 
painful,  and  last  for  shorter  or  longer  periods.  They  may  be  so  continuous 
that,  while  the  patient  is  awake,  his  face  exhibits  constant  twitchings.  The 
contractions  are  increased  by  physical  or  mental  fatigue  and  by  undue  emotion. 
Pressure  over  various  points  along  the  course  of  the  nerve  may  elicit  pain. 

A  tonic  form  of  the  disorder  may  occur  with  paralysis  or  from  cold  or,  more 
often  refiexly,  from  some  disturbance  of  the  eye. 

The  prognosis  of  facial  spasm  is  not  favorable  although  intermissions 
may  be  observed. 

Treatment  consists  in  removing  all  possible  causes  of  reflex  irritation, 
especially  in  the  eyes  and  teeth.  Counter-irritation  may  be  applied  along 
the  course  of  the  nerve  and  especially  over  the  points  which  are  tender  upon 
pressure.  Here  the  Paquelin  cautery  and  vesicants  may  be  useful.  Freez- 
ing of  the  affected  cheek  with  the  ethyl  chloride,  rhigolene  or  aether  spray 
for  a  few  moments  daily  may  prove  beneficial,  temporarily  at  least.  Hypo- 
dermatic injections  of  strychnine  have  been  recommended  and  such  drugs 
as  potassium  iodide,  arsenic,  iron,  atropine  and  curare  may  be  employed 
but  it  is  doubtful  if  they  will  cause  improvement.  Nerve  sedatives,  the 
bromides,  hyoscyamus  or  codeine  may  be   given. 

Electricity  in    the  form  of  galvanism  may  be  employed,  the  anode  being 


8o4  DISEASES    OF    THE    NERVOUS    SYSTEM. 

placed  over  the  tender  points  or  along  the  nerve  trunk.  Reflex  instances  may 
be  benefited  by  applying  the  positive  pole  to  the  nuchal  region  while  the  nega- 
tive pole  is  held  in  the  hand. 

Surgical  interference  consisting  of  division  of  the  nerve  and  making  an 
anastomosis  between  it  and  the  eleventh  nerve,  has  been  advocated.  Nerve 
stretching  may  afford  relief  although  this  may  be  but  transient,  the  spasm 
recurring  when  the  paralytic  effect  of  the  stretching  has  passed. 

DISEASES  OF  THE  EIGHTH  PAIR:  THE  AUDITORY  NERVES. 

Affections  of  the  eighth  nerve  may  result  from  lesions  in  any  part  of  its 
course.  Disease  at  its  nucleus  of  origin  is  rare;  in  its  course  it  is  subject 
to  involvement  in  fractures,  tumors,  inflammations  or  haemorrhages  and  in- 
flammation of  the  nerve  itself  occurs  as  a  complication  of  the  infectious 
diseases,  locomotor  ataxia  and  cerebrospinal  meningitis. 

The  two  branches  of  the  nerve  should  be  considered  separately  since  the 
cochlear  is  concerned  in  audition  and  the  vestibular  in  coordination. 

The  Cochlear  Nerve.  Lesions  such  as  tumor  at  the  cortical  auditory  center 
in  the  temporo-sphenoidal  lobe,  when  on  the  left  side,  cause  word  deafness; 
those  involving  the  course  of  the  cochlear  nerve  from  the  auditory  center 
to  its  origin  result  in  true  deafness. 

Pressure  upon  the  nerve  at  the  base  of  the  brain  from  tumors,  aneurysms, 
inflammatory  exudates,  haemorrhage,  or  injuries,  and  degeneration  of  the  nerve 
such  as  occurs  in  locomotor  ataxia,  may  produce  lesions  of  the  nerve  in  its 
course.  Deafness  also  may  be  caused  by  the  effects  of  epidemic  cerebrospinal 
meningitis  upon  the  nerve. 

Affections  of  the  internal  ear,  primary  or  as  a  result  of  middle  ear  lesions, 
are  the  most  frequent  causes  of  disorders  of  the  auditory  nerve. 

The  symptoms  produced  by  lesions  of  the  cochlear  branch  are  a,  auditory 
liyperEesthesia;    h,    irritation    of    the    auditory    nerve;  c,  nervous  deafness. 

Auditory  hyperesthesia  (hyperacusis)  is  a  condition  in  which  sounds  inaud- 
ible to  the  normal  individual  become  audible  and  ordinary  sounds  are  heard 
with  an  increased  intensity.  Dysesthesia  (dysacusis)  is  a  condition  charac- 
terized by  discomfort  upon  hearing  ordinary  sounds,  as  in  headache  when 
a  sound,  such  as  would  have  no  effect  under  normal  conditions,  increases 
the  pain.  These  affections  may  occur  in  hysterical  conditions  and  in  cere- 
bral disease. 

Treatment  shouldbe  directed  at  the  cause  of  the  condition  and  the  unpleasant 
symptoms  may  be  controlled  by  sedatives  such  as  the  bromides  and  valerian. 

Auditory  Irritation  (tinnitus  aurium).  Under  the  general  term  tinnitus 
are  classified  all  forms  of  abnormal  subjective  sensation  to  which  the  ear 
is  subject,  including  ringing,  buzzing,  hissing,  roaring  sounds,  etc.     Even 


DISEASES    OF    THE    EIGHTH    PAIR:    THE    AUDITORY    NERVES.        805 

the  sound  of  voices  may  be  heard.  The  sounds  vary  from  those  hardly 
noticeable  to  those  that  cause  profound  discomfort.  Bruits  may  be  heard 
synclironous  with  the  cardiac  systole  and  may  be  audible  through  the  stetho- 
scope applied  behind  the  ear,  clicking  sounds,  at  times  perceptible  to  the 
patient's  companions,  may  be  caused  by  spasm  of  the  palate  muscles.  The 
auditory  aura,  occurring  sometimes  in  epilepsy,  is  a  form  of  this  trouble. 
The  misery  induced  by  such  conditions  has  been  known  to  result  in  suicide. 

The  aetiology  may  be  difi&cult  to  discover.  The  ear  should  always  be 
examined  for  accumulations  of  cerumen  and  for  middle  ear  disease.  Gouty, 
anaemic  and  neurasthenic  conditions  are  often  responsible  for  tinnitus,  as  is 
the  administration  of  quinine  or  salicylic  acid  in  large  doses. 

Treatment  consists  in  measures  calculated  to  relieve  any  existing  aural 
lesion,  such  as  the  removal  of  impacted  cerumen,  the  exhibition  of  the  salic- 
ylates, the  iodides  and  colchicium  in  rheumatic  and  gouty  instances  and  of  iron 
and  arsenic  when  anasmia  seems  responsible.  Neurasthenia  should  receive 
appropriate  treatment  and  the  patient's  nutrition  and  general  hygiene  should 
be  considered. 

The  application  of  vesicants  or  even  of  the  actual  cautery  behind  the  ear, 
and  the  bromides,  either  alone  or  in  connection  with  small  doses  of  belladonna 
are  said  to  be  useful.  Glyceryl  nitrate  in  ascending  doses  until  the  physiolog- 
ical effect,  as  evidenced  by  feeling  of  fulness  in  the  head  and  dizziness  is  noted, 
is  also  recommended. 

Nervous  deafness  is  evidenced  by  diminution  of  the  ability  to  hear  sounds 
when  conducted  by  the  air,  while  sounds  conducted  tlirough  the  temporal 
bone  are  audible.  The  test  consists  in  holding  the  tuning  fork  near  the  ear, 
then  placing  it  in  contact  with  the  temporal  bone.  If  it  is  not  heard  in  the 
latter  case  the  loss  of  the  power  of  hearing  is  not  due  to  nerve  deafness. 

Treatment  is  likely  to  be  of  little  avail.  The  otologist  should  be  consulted 
and  a  careful  examination  of  the  organ  made;  the  management  of  the 
condition  belongs  rather  to  the  domain  of  the  specialist  than  to  that  of  the 
physician.  Antisyphilitic  treatment  should  be  given  when  indicated  and 
electricity  and  mild  counter-irritation  have  a  field  of  usefulness. 

The  Vestibular  Nerve.  Disturbances  of  this  structure  are  evidenced  by 
vertigo,  nystagmus  and  disorders  in  the  function  of  coordination  in  the  head, 
neck,  and  eyes. 

Meniere's  disease  or  aural  vertigo  is  a  condition  resulting  from  a  lesion 
of  the  labyrinth.  Its  pathology  is  indefinite;  it  occurs  much  more  frequently  in 
men  than  in  women  and  is  most  often  observed  between  the  ages  of  thirty  and 
sixty  years.  Exposure,  syphilis  and  gout  have  been  considered  aetiological 
factors  and  the  degeneration  occurring  in  such  affections  as  locomotor  ataxia 
and  that  of  senility,  as  well  as  vaso-motor  disturbances  of  the  labyrinthine 
vessels,  seem  to  have  influence  in  its  causation. 


8o6  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Symptoms.  The  onset  of  a  paroxysm  is  usually  sudden  and  may  occur 
without  assignable  cause  or  be  induced  by  coughing  or  sneezing.  Between 
the  attacks  the  patient  may  suffer  from  slight  dizziness.  The  paroxysm  is 
characterized  by  sudden  buzzing  noises  in  the  ears  and  marked  vertigo,  in 
which  the  patient  feels  as  if  he  were  staggering  or  falling,  the  surrounding 
objects  may  seem  to  be  ttirning  about  and  he  may  grasp  at  stationary  objects 
to  prevent  himself  from  falling  or  may  lose  consciousness  for  a  few  seconds. 
After  a  moment  or  two  the  dizziness  passes,  the  patient  being  left  faint,  pale 
and  nauseated  with  the  face  bathed  in  clammy  perspiration.  Aural  symptoms 
such  as  tinnitus  and  deafness  in  one  or  both  ears  may  occur  and  double  vision 
or  nystagmus  may  be  coincident.  The  deafness  is  never  complete,  is  of 
nervous  type  and  the  tinnitus  is  throbbing  or  roaring  in  character. 

The  paroxysms  appear  at  intervals  varying  from  a  few  days  to  a  few  weeks 
or  even  months. 

The  prognosis  depends  upon  the  cause.  If  this  can  be  eliminated  recovery 
is  possible  and  at  any  rate  improvement  may  be  expected.  In  less  favorable 
instances  deafness  results,  which  when  complete  is  unaccompanied  by  dizziness. 

The  disease  should  not  be  confounded  with  epidemic  paralytic  vertigo 
(Gerlier's  disease  or  kubisagari) — see  p.  218 — or  with  gastric  vertigo,  which 
is  not  accompanied  with  deafness. 

Treatment  consists  in  relieving  the  cause  of  the  condition  in  so  far  as  pos- 
sible. 

The  eyes  should  always  be  examined  for  errors  of  refraction,  correction  of 
which  may  afford  relief.  Gouty  patients  should  receive  the  salicylates,  colchi- 
cum  and  the  iodides;  the  first  of  these  should  not  be  given  in  suflScient  dosage 
to  induce  tinnitus.  Syphilitic  patients  should  receive  appropriate  medication. 
When  contraction  of  the  general  arterial  system  is  present  glyceryl  nitrate  or 
potassium  iodide  is  indicated.  Potassium  bromide  in  doses  of  15  to  30  grains 
(1.0-2.0)  three  times  a  day  may  be  employed  and  Charcot  has  recommended 
the  administration  of  quinine,  beginning  with  moderate  doses  and  gradually  in- 
creasing them  until  cinchonism  is  produced. 

Counter-irritation  behind  the  ears  in  the  form  of  blisters  may  prove  temporar- 
ily beneficial. 

DISEASES    OF    THE   NINTH  PAIR:    THE    GLOSSOPHARYNGEAL 

NERVES. 

Branches  from  this  pair  of  nerves  supply  sensory  fibres  to  the  upper 
part  of  the  pharynx,  the  tonsils  and  soft  palate,  innervate  the  stylophar- 
yngeus  and  middle  constrictor  of  the  pharynx  and  send  taste  fibres  to  the 
palate  and  posterior  third  of  the  tongue. 

Lesions  of  the  glossopharyngeal  nerve  result  from  tumors,  meningitis  and 


THE  PNEUMOGASTRIC  OR  VAGUS  NERVES.  807 

degenerative  processes;  the  nerve  is  seldom  affected  separately  because  of  its 
communications  with  others  of  the  cranial  nerves 

The  symptoms  of  disturbance  of  the  functions  of  this  nerve  are  anaesthesia 
of  the  parts  supplied  by  its  sensory  fibres,  paralysis  of  the  stylopharyngeus 
and  middle  pharyngeal  constrictor,  as  evidenced  by  difficulty  in  swallowing, 
and  gustatory  disorders  of  the  posterior  third  of  the  tongue  and  the  palate. 

Loss  of  taste  sense — ageusia — results  from  disorder  of  the  end  organs  in  the 
mucous  membrane  of  the  tongue  caused  by  the  habitual  use  of  strong  con- 
diments, such  as  pepper,  or  of  irritating  substances,  such  as  tobacco;  it  also 
occurs  in  the  dry  tongue  of  febrile  disease  and  the  coated  tongue  observed 
in  alimentary  disturbances.  Ageusia  is  a  symptom  of  affections  of  the  lingual 
branch  of  the  fifth  nerve,  of  the  trunk  of  the  fifth  before  it  leaves  the  skull, 
of  the  seventh  nerve  between  its  union  with  the  chorda  tympani  and  the  gen- 
iculate ganglion,  and  of  certain  cerebral  lesions. 

Perversion  of  taste  sense  {parageusia)  is  met  but  rarely  and  then  as  a 
symptom  of  hysteria  or  insanity.  Subjective  sensations  of  taste  also  occur 
in  the  insane  and  as  an  epileptic  aura. 

The  sense  of  taste  is  tested  by  causing  the  patient  to  close  his  eyes  and 
applying  such  substances  as  quinine,  sugar  solution,  salt  solution  and  vinegar 
to  the  anterior  and  posterior  parts  of  the  tongue.  A  feeble  galvanic  current 
gives  a  metallic  taste  and  is  a  useful  test.  It  is  important  that  the  test  should 
be  decided  while  the  tongue  is  protruded. 

DISEASES    OF    THE    TENTH   PAIR:  THE  PNEUMOGASTRIC  OR 

VAGUS   NERVES. 

The  extensive  distribution  of  this  pair  of  nerves  renders  them  liable  to  a 
variety  of  disturbances.  Their  nuclei  of  origin  in  the  floor  of  the  fourth  ven- 
tricle may  be  involved  in  bulbar  palsy,  they  may  be  subjected  to  pressure  in 
meningitis,  syphilitic  or  other  new  growths,  abscess,  aneurysms  or  haemor- 
rhages. Their  branches  inside  the  skull  are  subject  to  pressure  from  var- 
ious intra-cranial  lesions;  extra-cranial  branches  are  subject  to  traumatism, 
to  pressure  from  inflammatory  processes,  tumors  and  aneurysm,  and  may  be 
involved  in  true  neuritis. 

The  pharyngeal  branches  may  be  paralyzed  in  bulbar  paralysis  or  in  neuritis, 
especially  that  resulting  from  diphtheria.  If  but  one  side  is  affected  the 
distm-bance  of  swallowing  is  but  slight;  in  involvement  of  both  sides  degluti- 
tion is  attended  with  difficulty  and  liquids  may  regurgitate  from  the  nostrils. 

Spasm  of  the  muscles  of  deglutition  occurs  in  hysteria  and  in  true  and  pseudo- 
hydrophobia. 

The  laryngeal  branches.  The  laryngeal  paralyses  occurring  in  vagus 
lesions  are  of  several  types:     Unilateral  abductor  paralysis  is  most  frequently 


8oS 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


caused  by  aneurysm,  particularly  of  the  arch  of  the  aorta,  since  the  recurrent 
laryngeal  nerve  of  the  left  side  passes  around  this  structure.  The  nerve  of 
the  right  side  may  be  pressed  upon  by  pleural  thickenings. 

In  this  condition  the  voice  is  hoarse  or  brassy  and  there  may  be  slight  dys- 
pnoea. The  paralyzed  cord  is  seen  immovable  near  the  mid-line  of  the 
larynx. 

Bilateral  abductor  paralysis  is  met  in  bulbar  paralysis  and  locomotor  ataxia, 
in  hysteria,  as  a  result  of  intra-laryngeal  inflammations  and  degenerations,  as 
well  as  of  pressure  upon  both  recurrent  laryngeal  nerves.  The  symptoms  are 
inspiratory  stridor  and  dyspnoea.  The  voice  is  unaffected  and  cough  is 
absent.  The  dyspnoea  is  due  to  the  close  approximation  of  the  vocal  cords 
during  inspiration  and  may  necessitate  intubation  or  tracheotomy.  Laryn- 
goscopic  examination  reveals  the  vocal  cords  in  close  proximity  to  one  another. 

Adductor,  phonic  or  hysterical  paralysis  is  seen  in  hysteria,  in  catarrhal 
laryngitis  and  as  a  result  of  over-use  of  the  voice  and  is  an  affection  of  the 
crico-arytenoid  and  arytenoid  muscles  themselves.  Examination  reveals  an 
inability  to  approximate  the  vocal  cords  on  attempt  at  phonation. 

The  table  given  below  (Gowers)  will  be  found  useful  in  differentiating  the 
various   types   of   laryngeal   paralysis. 


SYMPTOMS. 

SIGNS.                                                   LESION. 

No   voice;  no  cough;   stridor 
only  on  deep  inspiration. 

Both   cords   moderately  ab- 
ducted and  motionless. 

Total  bilateral  palsy. 

Voice  low-pitched  and  hoarse; 
no  cough;  stridor  absent  or 
slight  on  deep  breathing. 

One    cord    moderately     ab- 
ducted and  motionless,  the 
other  moving   freely,  and 
even   beyond    the   middle 
line  in  phonation. 

Total  unilateral  palsy. 

Voice    little    changed;    cough 
normal;  inspiration  difEcult 
and  long,  with  loud  stridor. 

Both   cords    near    together, 
and      during      inspiration 
not    separated,    but    even 
drawn  nearer  together. 

Total  abductor  palsy 

Symptoms  inconclusive;  little 
affection  of  voice  or  cough. 

One   cord   near  the   middle 
line    not    moving    during 
inspiration,  the  other  nor- 
mal. 

Unilateral  abductor  palsy. 

No    voice;  perfect  cough;  no 
stridor  or  dyspnoea. 

Cords    normal     in    position 
and    moving   normally  in 
respiration,     but     not 
brought    together    on    an 
attempt  at  phonation. 

Adductor  palsy. 

Spasm  of  the  laryngeal  muscles  affects  the  adductors  only;  Is  seen  in  children 
as  laryngismus  stridulus  and  rarely  in  the  adult;  it  is  characterized  by  very 


THE    PNEUMOGASTRIC    OR    VAGUS    NERVES.  809 

marked  dyspnoea,  so  persistent  at  times  as  to  cause  cyanosis.  The  attacks 
usually  come  on  at  night.  The  laryngeal  crisis  of  locomotor  ataxia  is  a  laryn- 
geal spasm.  Spastic  aphonia  is  a  condition  in  which  phonation  is  prevented 
by  spasm. 

Laryngeal  anczsthesia  is  met  in  bulbar  paralysis,  in  the  neuritis  of  diphtheria 
and  in  hysteria.  It  is  important  that  it  should  be  recognized  since  particles 
of  food  may  block  the  trachea  or  be  drawn  into  the  lungs.  Dysphagia  is  a 
common  symptom  of  this  afFection. 

The  cardiac  branches.  The  nerve  supply  of  the  heart  is  derived  from  the 
vagus  and  sympathetic  nerves.  The  vagus  supplies  motor,  sensory  and 
probably  trophic  fibres. 

The  motor  fibres  of  the  vagus  inhibit,  control  and  regulate  the  action  of 
the  heart.  Irritation  of  these  has  an  inhibitory  influence  upon  the  cardiac 
rate  which  results  in  retardation  of  the  pulse  (bradycardia).  Entire  vagus 
paralysis  results  in  loss  of  this  inhibitory  influence,  consequently  the  cardiac 
accelerator  action  is  uncontrolled  and  the  heart  rate  becomes  rapid  (tachy- 
cardia). It  is  an  interesting  point  that  total  paralysis  of  one  pneumogastric 
may  be  without  symptoms.  Disorders  of  the  motor  functions  of  the  vagus 
may  result  from  the  pressure  of  new  growths,  accidental  ligation  or  injury  of 
the  nerve,  neuritis  or  irritation  at  its  nuclei  of  origin.  Individuals  are  on 
record  who  seemed  to  have  voluntary  control  over  the  heart's  action,  and  it  is 
possible  in  some  instances  to  slow  the  pulse  rate  by  pressure  over  the  nerve 
in  the  neck. 

Sensory  disorders  of  the  vagus  are  rare  and  obscure,  but  the  sensations 
accompanying  palpitation,  pain  or  irregularity  are  transmitted  through  this 
nerve. 

The  theory  that  the  vagus  exercises  a  trophic  influence  is  based  upon  the 
fact  that  fatty  degeneration  of  the  heart  has  occurred  after  injury  to  this 
structure. 

The  gastric  and  oesophageal  branches.  The  vagus  sends  motor  and 
sensory  fibres  to  the  stomach.  Through  the  former  both  central  and  reflex 
excitation  cause  vomiting.  The  peristalsis  of  the  stomach  is  presided  over 
by  the  vagus  but  that  other  influence  is  also  at  work  here  is  evidenced  by  the 
fact  that  section  of  this  nerve  is  not  followed  by  the  subsidence  of  all  gastric 
motion.     Esophageal  spasm  and  deglutition  are  controlled  by  these  fibres. 

The  sensory  impulses  conveyed  through  the  pneumogastric  nerve  are 
believed  to  be  those  of  hunger  and  thirst  since  these  have  been  lost  in  lesions 
affecting  its  root;  however,  in  some  instances  of  disease  of  the  nerve  the  appetite 
has  remained  normal  or  has  been  abnormally  increased.  The  gastric  crises 
of  locomotor  ataxia  are  the  result  of  central  irritation  of  the  nuclei  of  origin 
of  this  nerve. 

The  pulmonary  branches.     Of  the  function  of  these  little  is  known.     It 


8lO  DISEASES    OF    THE    NERVOUS    SYSTEM. 

is  supposed  that  they  supply  the  bronchial  musculature  and  asthma  has  been 
considered  a  neurosis  of  these  fibres.  The  changes  in  the  rate  of  respiration 
are  believed  to  be  due  rather  to  the  respiratory  center  than  to  vagus  in- 
fluence.    Hiccough  may  result  from  lesion  of  this  nerve. 

The  course  and  prognosis  of  disorders  of  the  pneumogastric  nerve  vary 
with  the  cause  of  the  condition  in  question.  In  those  due  to  central  lesion 
or  intra-thoracic  neoplasms  or  aneurysms  it  is  not  encouraging,  while  those 
resulting  from  local  affections  and  hysteria  may  be  favorably  affected  by  proper 
treatment. 

Treatment  depends  altogether  upon  the  aetiology  of  the  condition  under 
consideration.  Central  disease  of  syphilitic  nature  should  be  amenable  to 
the  influence  of  potassium  iodide  in  ascending  doses  or  to  the  syrup  of  hydriodic 
acid,  one  drachm  (4.0)  three  times  a  day.  Laryngeal  paralyses  due  to 
recurrent  nerve  pressure  from  tumor  or  aneurysm  are  hopeless  unless  the 
tumor  is  specific  in  nature  or  removable  by  operation.  In  patients  of  rheu- 
matic tendency  the  possibility  of  this  element  in  the  causation  of  laryngeal 
muscular  disorders  must  be  considered.  Here  the  salicylates,  alkalies  and 
iodides  may  prove  beneficial.  Wlien  the  affection  is  a  part  of  a  general 
neuritis  the  treatment  is  that  of  this  condition  (see  p.  788). 

Paralyses  of  inflammatory  origin  should  receive  local  treatment  (see  p.  78S), 
in  those  due  to  hysteria  the  electric  current  is  indicated  and  the  daily  hypo- 
dermatic administration  of  strychnine  nitrate  in  doses  of  -gV  to  -jV  of  ^ 
grain  (0.001-0.003)  is  useful.  Laryngeal  exercises  and  massage  performed 
by  grasping  the  upper  and  back  part  of  the  thyroid  cartilage  between  thumb 
and  forefinger  and  phonating  at  the  same  time,  mav  also  be  employed. 

The  inhibitory  fibres  of  the  vagus  may  be  stimulated  in  tachycardial  states 
by  digitalis  and  in  bradycardia  due  to  hyper-irritation  of  the  cardio-depressory 
apparatus,  atropine  may  be  found  useful.  The  general  condition  of  the  patient 
may  require  general  hygienic  and  tonic  treatment. 

DISEASES  OF  THE  ELEVENTH  PAIR:  THE  SPINAL  ACCESSORY 

NERVES. 

Paralysis  or  spasm  of  this  pair  of  nerves  may  occur  as  a  result  of  involve- 
ment of  their  nuclei  in  bulbar  paralysis;  its  external  nuclei  in  the  cervical  region 
of  the  cord  may  be  affected  in  degenerative  processes  of  the  motor  nuclei  of  the 
cord;  within  the  cranium  the  nerve  is  subject  to  pressure  from  tumors  and 
meningeal  exudates,  and  outside  the  skull  it  is  subject  to  injury  and  to  in- 
volvement in  tumors,  vertebral  necrosis  and  cervical  abscesses. 

The  internal  or  smaller  division  of  this  nerve  joins  the  vagus  and  supplies 
through  it  the  muscles  of  the  larynx.     Paralysis  of  this  portion  has  been 


THE    SPINAL    ACCESSORY    NERVES.  8ll 

discussed  under  laryngeal  paralyses.  The  external  or  spinal  division  inner- 
vates the  sterno- mastoid  and  trapezius  muscles. 

Paralysis  of  the  external  portion  of  the  nerve  is  evidenced,  when  unilateral, 
by  interference  with  the  rotation  of  the  head  toward  the  sound  side;  torticollis 
is  absent  but  the  head  may  be  held  in  an  oblique  position.  The  trapezius, 
receiving,  as  it  does,  innervation  from  other  sources,  is  only  partially  paral- 
yzed; that  part,  however,  which  extends  from  the  acromion  process  to  the 
occiput  is  useless  and  the  middle  portion  of  the  muscle  is  weakened,  conse- 
quently the  shoulder  is  slightly  lower  than  normal  and  is  rotated  inward  by 
the  unopposed  action  of  the  rhomboids  and  the  levator  anguli  scapulse.  In 
respiration  and  shrugging  of  the  shoulders  the  disorder  is  plainly  evidenced 
and  there  is  imperfect  ability  to  lift  the  arm  since  the  trapezius  fails  to  fix 
the  scapula  and  to  give  the  deltoid  a  point  from  which  to  work;  atrophy  and 
the  reaction  of  degeneration  are  usual. 

Bilateral  paralysis  is  evidenced  by  loss  of  power  to  hold  the  head  upright. 
If  the  sterno-mastoids  are  involved,  the  head  is  prone  to  fall  backward;  if  the 
trapezii  are  affected  it  droops  forward,  a  characteristic  of  progressive  muscu- 
lar atrophy  and  also  a  symptom  of  meningitis  in  the  neighborhood  of  the 
foramen  magnum  and  of  cervical  meningitis  following  caries  of  the  spine. 
Injury  of  the  spinal  accessory  nerves  during  childbirth  may  cause  a  falling 
forward  of  the  child's  head  lasting  usually  not  beyond  the  first  year. 

The  treatment  of  these  conditions  should  strike  at  the  aetiological  factor. 
If  the  disease  is  central  the  condition  is  hopeless.  Pressure  paralyses  may  be 
relieved  by  surgical  or  orthopaedic  measures;  this  done  the  wasted  muscles 
should  be  treated  by  massage  and  the  electric  current.  Faradism  is  more 
effectual  than  galvanism. 

Accessory  spasm,  torticollis  or  wry  neck  is  caused  principally,  although 
not  entirely,  by  spasm  of  the  muscles  supplied  by  the  eleventh  nerve;  two 
types  are  described. 

a.  Congenital  or  Fixed  Torticollis.  This  condition  affects  the  right  side 
more  usually  and  may  result  from  injury  to  the  sterno-mastoid  during  labor 
or  occur  as  a  congenital  developmental  defect.  Injury  of  the  muscle  followed 
by  cicatricial  contraction  may  produce  a  like  condition  later  in  life.  The 
muscle  is  shortened,  tense,  firm  and  usually  atrophic,  and  associated  with 
the  congenital  type  is  an  asymmetry  of  the  face  which  may  be,  together  with 
the  wry  neck,  the  result  of  some  central  cause  analogous  to  that  producing 
talipes. 

The  treatment  of  this  condition  is  wholly  surgical  or  orthopaedic,  and  often 
is  quite  satisfactory  although  the  facial  asymmetry  sometimes  persists  or  be- 
comes more  marked. 

The  operations  applicable  to  the  condition  are  those  of  section  of  the  muscle 
or  tenotomy. 


8l2  DISEASES    OF    THE    NERVOUS    SYSTEM. 

b.  Spasmodic  Torticollis.  This  affection  occurs  in  both  a  tonic  and  a  clonic 
form.  Both  varieties  may  occur  in  the  same  case  or,  what  is  more  usual 
the  condition  assumes  at  its  outset  one  type  and  does  not  change.  It  is 
observed  most  often  in  adults  and  in  America  seems  more  frequent  in  males, 
although  the  opposite  appears  to  be  the  case  in  England.  Exposure  and  trauma 
are  factors  in  its  aetiology;  it  may  be  due  to  hysteria  and  is  prone  to  occur  in 
individuals  of  neurotic  heredity. 

The  tonic  type  is  evidenced  by  approximation  of  the  occiput  to  the  shoulder 
on  the  affected  side,  elevation  of  the  chin  and  turning  of  the  face  toward  the 
sound  side.  This  position  is  due  to  contraction  of  the  sterno-mastoid.  Involve- 
ment of  the  trapezius  draws  the  occiput  still  further  downward  and  toward 
the  side  affected.  The  affected  muscles  are  tense  and  prominent  and  their 
continued  rigidity  may  produce,  in  long-standing  cases,  a  spinal  curvature 
(scoliosis)  with  its  convexity  toward  the  unaffected  side.  Involvement  of 
the  scaleni  and  the  platysma  and  rarely  of  some  of  the  deep  muscles  of  the  neck 
may  co-exist.  Bilateral  spasm  (retro-coUic  spasm)  draws  the  head  backward, 
even  so  far  that,  in  extreme  instances,  the  face  is  directed  upward. 

In  the  clonic  form  attacks  of  twitching  of  the  head,  sometimes  of  severe  type, 
may  appear  without  previous  symptoms  or  they  may  be  preceded  by  pain  or 
stiffness.  In  unilateral  spasm  of  the  sterno-mastoid  each  contraction  turns 
the  head  toward  the  unaffected  side  and  raises  the  chin;  when  the  trapezius 
is  involved  the  head  is  drawn  back  and  toward  the  shoulder  of  the  same  side. 
In  bilateral  spasm  of  both  sides  there  is  paroxysmal  retro-coUic  spasm  at  times 
combined  with  nodding  movements;  the  movements  may  occur  every  moment 
or  two  and  the  head  cannot  be  kept  still.  Enlargement  of  the  muscles  induced 
by  their  continued  exercise  results.  Other  muscles  of  the  neck  may  be  affected 
and  at  times  even  those  of  the  arms.  During  sleep  the  contractions  cease; 
after  fatigue,  excitement  or  emotion  they  are  accentuated.  Pain  may  accom- 
pany the  spasms. 

The  condition  is  an  obstinate  one.  Treatment  may  have  little  effect  and, 
at  best,  recurrences  are  frequent. 

Treatment  consists  in  the  removal  of  the  cause  of  the  condition  if  this  can 
be  ascertained.  Acute  attacks  necessitate  confinement  to  bed  and  the  appli- 
cation of  heat,  moist  or  dry.  Large  doses  of  the  bromides  may  lessen  the 
spasms  and  other  sedatives  may  be  employed.  The  fluidextract  of  cannabis 
indica  in  increasing  doses  has  been  given  but  little  benefit  is  to  be  expected 
from  its  use.  Morphine  hypodermatically  will  relax  the  spasm  but  the  danger 
of  producing  the  habit  should  never  be  forgotten.  Recoveries  have  been 
reported  due  to  this  drug  given  for  several  months  in  doses  increased  to  i 
grain  (0.065)  daily  but  it  is  likely  that  when  the  patient  is  cured  of  his  spasm 
that  the  physician  will  have  induced  the  morphine  habit  and  will  then  have 
this  condition  to  deal  with. 


THE    HYPOGLOSSAL    NERVES.  813 

The  hypodermatic  injection  of  atropine  into  the  muscles  involved  has  been 
advocated. 

Electricity  may  prove  beneficial.  Both  galvanism  and  faradism  may  be 
employed;  if  the  former,  the  current  should  be  weak,  the  positive  pole  being 
applied  to  the  occipital  insertions  of  the  sterno-mastoid  and  trapezius,  and 
the  negative  to  each  affected  muscle  in  turn  for  ten  or  fifteen  minutes.  Farad- 
ism should  be  applied  by  brushing  the  involved  muscles,  the  current  being 
gradually  increased  in  strength. 

Surgical  treatment  consisting  of  stretching,  section,  or  excision  of  the  nerve, 
may  give  temporary  relief  and  the  more  radical  procedure  of  dividing  the 
spinal  accessory  nerve  together  with  resection  of  the  posterior  branches  of 
the  upper  two  or  three  cervical  nerves  may  diminish  the  spasm. 

DISEASES  OF  THE  TWELFTH  PAIR:  THE  HYPOGLOSSAL 

NERVES. 

Paralysis  of  this,  the  motor  nerve  of  the  tongue  and  of  the  depressors  of 
the  hyoid  bone  and  of  the  hyoglossus  and  geniohyoid  muscles,  takes  place  in 
cortical  lesions  such  as  apoplexy,  cerebral  compression,  thrombosis,  embolism 
and  softening,  and  in  nuclear  and  infra-nuclear  disease.  In  the  latter  lesions 
the  disturbance  of  the  hypoglossal  nerve  results  rather  from  slow  degener- 
ation such  as  usually  occurs  in  bulbar  paralysis  and  locomotor  ataxia,  than 
from  acute  softening.  Tumors,  basilar  meningitis,  and  lesions  of  the  cranial 
bones  may  involve  the  nerve,  and  outside  the  skull  it  is  subject  to  injury, 
involvement  in  a  cicatrix  and  pressure  by  tumors.  Neuritis  of  the  twelfth 
nerve  may  occur  as  part  of  a  polyneuritis. 

Paralysis  of  the  hypoglossal  nerve  is  characterized  by  loss  of  motility  of 
the  tongue.  In  unilateral  paralysis  only  half  the  organ  is  involved  and  it  is 
protruded  toward  the  affected  side;  in  bilateral  palsy  the  organ  remains 
without  motion  in  the  floor  of  the  mouth;  speech  is  difficult,  mastication  and 
swallowing  are  interfered  with.  There  is  partial  or  complete  atrophy  of 
the  tongue,  as  the  case  may  be,  and  its  mucous  membrane  is  thrown  into  folds. 
In  disease  above  the  nuclei  the  atrophy  is  absent  and  the  electrical  reaction 
remains  normal.  If  the  causative  lesion  is  below  the  nuclei  there  may  be 
fibrillary  twitching  and  the  reaction  of  degeneration  is  present. 

Spasm  is  rare  unaccompanied  by  other  manifestations  and  may  be  unilateral 
or  bilateral.  Usually  it  is  associated  with  some  other  convulsive  disturbance 
such  as  chorea,  epilepsy  or  spasm  of  the  muscles  of  the  face;  in  some  instances 
of  stammering,  spasm  of  the  tongue  precedes  the  utterance  of  the  words; 
it  may  be  observed  in  hysteria  or  result  from  irritation  of  the  fifth  nerve. 
It  is  more  often  bilateral  and  may  occur  paroxysmally;   in  severe  instances  the 


8l4  DISEASES    OF    THE    NERVOUS    SYSTEM. 

tongue  may  be  quickly  thrust  in  and  out  many  times  a  minute  and  this  may 
persist  during  sleep. 

Treatment  should  be  directed  at  the  causative  lesion  and  should  this  prove 
incurable,  the  condition  is  likely  to  prove  permanent.  In  paralysis,  electricity 
may  be  employed,  the  electrode  applied  to  the  tongue  being  in  the  form  of  a 
tongue  depressor.  Electricity  may  be  used  in  spasm  also  and  here  good 
results  may  attend  the  administration  of  the  bromides  and  other  sedatives. 
Potassium  iodide  is  also  recommended. 


FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM. 
ACUTE  CHOREA. 

Synonyms.     Sydenham's  Chorea;  Chorea  Minor;  St.  Vitus'  Dance. 

Definition.  A  disease  characterized  by  irregular  involuntary  contractions 
of  the  muscles,  sometimes  accompanied  by  mental  disorder  and  frequently 
associated  with  endocarditis  and  rheumatism.  It  is  most  often  seen  in 
children. 

.Etiology.  Chorea  occurs  chiefly  between  the  ages  of  five  and  fifteen  and 
seems  to  affect  females  more  often  than  males.  It  is  more  common  in  the 
lower  walks  of  life  and  heredity  may  have  some  influence  in  its  causation.  It 
is  rare  in  negroes  and  has  never  been  observed  among  the  American  aborigenes. 
The  nervous  temperament  is  a  predisposing  cause;  emotional  excitement, 
fright  and  grief,  as  well  as  over-study,  may  excite  the  disease.  Imitation  is 
considered,  at  present,  to  have  little  influence  as  an  agtiologic  factor,  and  the 
same  is  true  of  reflex  irritation,  digestive  and  otherwise,  as  well  as  of  eye- 
strain. 

Chorea  has  been  considered  closely  associated  with  acute  articular  rheu- 
matism by  English  and  French  authorities  for  many  years,  German  observers 
however,  do  not  regard  their  connection  as  so  intimate.  The  chorea  may 
succeed  the  joint  manifestations  after  considerable  periods  of  time,  while  in 
other  cases  the  arthritis  may  be  closely  followed  or  be  accompanied  by  this 
disease.  It  is  probable  that  the  joint  symptoms  are  often  overlooked,  since 
rheumatism  in  children  may  be  manifested  by  any  slight  swelling  of  a  single 
joint  or  by  vague  pains.  While  the  so-called  growing  pains  of  children  may 
be  rheumatic  in  character  it  is  well  to  keep  in  mind  the  fact  that  this  is  not 
always  the  case. 

Endocarditis  has  been  held  to  be  a  cause  of  the  disease  and  is  often  asso- 
ciated with  it.  '  Chorea  has  followed  the  acute  infectious  diseases,  such  as 
pyaemia,  gonorrhoeal  and  syphilitic  constitutional  infection,  puerperal  septic- 
aemia, diphtheria,  scarlatina,  measles,  typhoid  fever,  etc.,  but  it  is  probable  that 


ACUTE    CHOREA.  815 

the  relationship  between  chorea  and  these  affections  is  not  close.  Anaemia 
may  act  as  a  predisposing  cause  and  often  results  from  this  disease  and  it 
may  occur  during  pregnancy.  Poisoning  by  iodoform,  carbon  dioxide  and 
other  substances  have  seemed  to  cause  short  attacks. 

Pathology.  There  are  no  definitely  recognized  post  mortem  changes 
characteristic  of  chorea;  the  numerous  lesions  which  have  been  found  are  due 
to  complications  or  are  coincident.  The  accepted  theory  of  the  disease 
is  that  it  is  a  functional  affection  of  the  nerve  centers  presiding  over  the 
motor  apparatus.  Associated  with  chorea  have  been  found  endocarditis 
in  a  large  majority  of  cases,  pericarditis  and  other  miscellaneous  diseases. 

The  embolic  theory  of  chorea  based  upon  the  finding  of  emboli  in  the  cere- 
bral vessels,  will  not  account  for  all  instances;  for  while  such  lesions  have  been 
made  out  in  a  number  of  instances,  there  are  others  in  which  these  were 
wholly  absent  even  when  distinct  endocarditis  existed. 

With  regard  to  the  consideration  of  chorea  as  an  infectious  disease  nothing 
has  as  yet  been  definitely  proven. 

Symptoms.  The  onset  of  the  disease  is  usually  gradual,  the  first  manifes- 
tations being  those  of  excessive  nervousness,  with  restlessness  and  mental 
irritability.  The  condition  occurs  in  three  types  which  differ  mainly  in 
degree. 

a.  The  mild  variety  with  only  slight  involvement  of  the  muscles  and  only 
slight  disorder  of  speech  and  general  health. 

b.  The  severe  form  with  generalized  choreic  movements,  inability  to  talk 
and  to  perform  the  ordinary  duties  of  life. 

c.  The  maniacal  type. 

After  the  restlessness  and  irritability,  the  motor  symptoms  are  first  to  appear. 
These  usually  involve  the  upper  extremities,  later  the  face  and  still  later  the 
legs,  although  rarely  the  legs  may  be  first  affected  or  the  movements  may  be 
general  from  the  outset.  The  patient  drops  objects  and  is  unable  to  dress 
or  feed  himself,  the  gait  is  disturbed  and  there  may  be  spasms  of  the  facial 
muscles.  The  spasmodic  movements  may  finally  extend  to  all  parts  of  the 
body  or  are  limited  to  one  side  (hemichorea),  they  are  irregular,  jerking, 
arrhythmical  and  vary  from  an  almost  unnoticeable  contraction  of  the  muscles 
to  constant  twitchings.  They  are  wholly  involuntary  and  efforts  at  control 
often  increase  them.  They  are  augmented  by  fatigue  or  excitement  but 
seldom  persist  during  sleep. 

Speech  is  involved  in  many  patients  and  the  disturbance  of  this  function 
varies  from  mere  hesitance  to  entire  incoherence.  Muscular  weakness  appears 
as  the  disease  progresses  and,  in  consequence,  the  patient's  gait  may  be  limp- 
ing and  his  grip  weakened. 

Sensory  manifestations  are  not  marked  although  there  may  be  pain  and 
tenderness  in  the  limbs.     Pain  may  be  elicited  by  pi'essure  over  the  points  of 


8l6  DISEASES   OF    THE    NERVOUS    SYSTEM. 

emergence  of  the  spinal  nerves  and  sensations  of  numbness  or  tingling  may- 
occur.  The  reflexes  usually  remain  normal  but  may  be  exaggerated  or  lost. 
Trophic  manifestations  are  very  seldom  observed. 

Mental  symptoms  are,  as  a  rule,  not  marked  but  melancholic  states  and 
hallucinations  may  occur.  Chorea  insaniens  may  develop  from  the  milder 
types  and  is  most  common  in  v^^omen. 

Heart  symptoms  are  very  common  and  this  organ  should  be  most  closely 
watched  in  all  cases.  Irregularity  of  the  cardiac  pulsations  and  particularly 
increased  rapidity  of  its  action  are  very  common  and  in  cases  associated  with 
anaemia,  the  haemic  murmur,  a  soft  ventriculo-systolic  bruit  at  the  base  or  apex, 
is  very  frequently  audible. 

True  endocarditis  in  chorea  is  seldom  evidenced  by  symptoms,  but  frequent 
physical  examination  of  the  heart  in  a  great  majority  of  patients  will  reveal  the 
presence  of  organic  cardiac  lesion.  Any  of  the  valves  may  be  attacked  but 
those  of  the  left  heart  are  by  far  the  most  likely  to  be  affected.  The  endocar- 
ditis is  of  the  simple  verrucous  type  as  a  rule  and  is  likely  in  many  instances  to 
result,  in  after  years,  in  permanent  valvular  disorder.  Pericarditis  not  infre- 
quently complicates  chorea,  especially  rheumatic  instances. 

Rise  of  temperature  in  chorea  is  usually  due  to  complicating  conditions, 
except  in  the  maniacal  type,  when  a  febrile  movement  even  as  high  as  104° 
F.  (40°  C.)  may  occur.  At  times  the  surface  temperature  of  the  affected  side 
in  unilateral  chorea  may  be  slightly  elevated. 

Skin  afl'ections  are  sometimes  seen  and  are  often  due  to  the  continued  admin- 
istration of  arsenic.  This  drug  causes  spots  of  pigmentation,  herpetic,  papil- 
lary and  erythematous  eruptions.  Other  cutaneous  manifestations  observed 
in  chorea  are  usually  rheumatic  in  character  such  as  erythema  nodosum, 
purpuric  urticaria  or  the  peliosis  rheumatica  of  Schonlein.  Sometimes  the 
excessive  motion  may  abrade  the  skin  in  exposed  localities. 

The  prognosis  as  regards  recovery  in  chorea,  except  in  the  maniacal  type, 
which  is  usually  fatal,  is  good,  two  to  three  months  being  the  usual  duration 
of  an  ordinary  case;  recurrences  are  frequent,  however,  and  while  the  com- 
plications involving  the  heart  may  not  result  in  permanent  affection  of  this 
organ,  they  are  only  too  likely  to  become  chronic  and  distressing. 

Instances  of  chorea  in  which  the  duration  of  the  disease  is  unusually  pro- 
tracted should  be  examined  for  causes  of  peripheral  irritation.  The  chorea 
of  pregnancy  is  of  severe  type. 

Treatment.  The  prophylaxis  of  chorea  is  important  and  consists  in  care- 
fully watching  all  unusually  bright  children,  especially  if  of  neurotic  heredity, 
and  preventing  any  over-study  or  other  mental  over-activity.  Competitions 
for  school  prizes  should  be  heartily  discouraged. 

The  general  hygienic  treatment  of  this  disease  consists  of  removal  from 
school  and  seclusion  from  all  excitement.    The  patient  should  not  be  reproved 


ACUTE    CHOREA.  817 

or  ridiculed  because  of  his  movements  and  his  small  faults  and  wrong  doings 
should  be  condoned.  In  the  milder  instances  the  patient  need  not  be  confined 
to  bed  but  in  those  of  severer  type  it  is  best  to  advise  this  measure.  When  pos- 
sible, a  trained  nurse  should  be  procured  and  the  patient  should  be  separated 
as  far  as  possible  from  exciting  and  disturbing  influences.  Oftentimes  it  is 
better  to  keep  the  child  from  his  parents  and  relatives  since  sympathy  and 
indulgence  accentuate  the  condition.  Patients  who  have  done  poorly  at  home 
often  begin  to  improve  at  once  in  a  hospital  where  they  are  properly  restrained 
and  encouraged  toward  self-control.  The  importance  of  rest  in  bed  is  par- 
ticularly to  be  emphasized  in  cases  in  which  there  is  any  suggestion  of  a 
heart  lesion.  Here  massage  and  warm  bathing  are  of  great  benefit.  In  mild 
instances  which  are  allowed  to  be  up,  gymnastics  may  be  employed  but  only  in 
moderation  and  under  intelligent  supervision.  In  the  severe  instances  they  may 
do  positive  harm.  Cold  sponging  is  also  of  benefit  in  the  mild  type  of  the 
disease. 

The  drug  which  seems  to  affect  chorea  most  favorably  is  arsenic;  it  probably 
has  no  specific  action,  its  beneficial  effect  being  due  to  its  improving  influ- 
ence upon  the  general  condition.  Liquor  potassii  arsenitis  (Fowler's  solution) 
is  the  preparation  to  be  preferred.  Often  it  seems  to  fail  because  of  insuffi- 
cient dosage.  The  beginning  dose  for  a  child  of  eight  to  ten  years  is  from  four 
to  five  drops  (0.26-0.33)  three  times  a  day  and  increased  by  one  drop  (0.065) 
daily  until  the  physiological  effect  is  manifest  as  evidenced  by  disturbance  of 
the  alimentary  tract  and  oedema  under  the  eyes.  When  this  occurs  the  drug 
should  be  stopped,  to  be  resumed  after  several  days  in  the  same  dosage  as 
when  left  off  and  continually  increased  until  from  fifteen  to  twenty-five  drops 
(1.0-T.66)  are  taken  at  each  dose.  The  solution  should  be  given  after  meals 
and  well  diluted.  Wlien  the  movements  cease  the  drug  should  be  stopped. 
Arsenical  poisoning  seldom  occurs  but  in  very  rare  instances  a  neuritis  has 
been  induced. 

In  rheumatic  patients,  where  other  drugs  have  no  influence,  sodium  salicylate 
in  full  dosage  should  be  administered  and  may  effect  permanent  cvue. 

Opium  or  morphine  should  not  be  employed,  except  in  instances  marked 
by  insomnia  and  restlessness;  the  bromides  are  useful  and  in  very  severe 
and  obstinate  instances  hydrated  chloral  may  be  given. 

In  mild  instances  good  results  have  followed  the  administration  of  an  infusion 
of  cimicifuga  racemosa  (black  snakeroot)  in  doses  of  i  or  2  ounces  (30.0- 
60.0)  two  or  three  times  a  day.  The  zinc  salts,  silver  nitrate  and  copper 
sulphate  are  little  used  at  present.  The  use  of  hyocsyamine  hydrobromide, 
given  hypodermatically  in  doses  of  y^-g-  of  a  grain  (0.0006)  three  times  a 
day,  has  been  recommended  and  hyoscyamus  may  be  given  in  combination 
with  zinc  valerate  as  in  the  following  formula:  I^  zinci  valeratis,  extracti 
hyoscyami,  bismuthi  subnitratis  aa  gr.  xv  (i.o).  Massa  fiat  et  divide  in  pilulas 
52 


8l8  DISEASES    OF    THE    NERVOUS    SYSTEM, 

no.  XXV.  Sig.,  three  to  six  pills  daily.  Antipyrine  may  succeed  in  certain  cases 
where  other  means  fail  and  may  be  given  in  doses  of  from  7  to  10  grains 
(0.5-0.66)  three  times  a  day  to  a  child  of  eight  years.  Strychnine  may  be 
useful  in  certain  patients  and  from  y^^  to^^of  a  grain  (0.0006-0.001)  may 
be  given  three  times  a  day.  Aspirin  is  advocated  in  severe  and  persistent 
instances  and  should  be  particularly  effective  in  those  in  which  the  rheumatic 
element  is  present.  In  children  over  seven  the  beginning  dose  is  10  grains 
(0.66)  twice  a  day  increased  to  10  or  15  grains  (0.66-1.0)  four  times  a  day. 
This  drug  may  cause  gastric  irritation  and  tinnitus.  Cerebrin  is  another 
drug  which  has  been  recently  recommended. 

Very  severe  and  otherwise  uncontrollable  movements  may  necessitate  the 
intermittent  administration  of  chloroform. 

For  the  anaemia  which  frequently  is  co-existent  with  chorea,  iron  should 
be  given  either  in  the  form  of  the  Blaud  pill  (pilula  ferri  carbonatis)  one  or  two, 
three  times  a  day,  in  mixture  such  as  the  following:  I^  ferri  citratis, oii  (8.0); 
syrupi,  5iv  (16.0);  aquae  aurantii  fiorum,  oiss  (48.0).  Misce  et  signa,  one  tea- 
spoonful  (4.0)  three  times  a  day,  or  in  the  form  of  iron  vitellin.  The  iron 
mav  often  be  advantageously  combined  with  arsenic.  Electricity  may  prove 
beneficial  on  account  of  its  tonic  effect. 

The  eyes  and  nose  should  always  be  thoroughly  examined  for  sources  of 
reflex  irritation  and  when  present  these  should  be  corrected.  The  possibility 
of  the  presence  of  intestinal  parasites  should  also  be  considered. 

The  general  nutrition  should  receive  particular  attention;  the  food  should 
be  easily  digestible  and  nourishing;  tea  and  coffee  should  be  prohibited.  The 
bowels  should  be  kept  open. 

Cases  which  go  on  for  considerable  periods  resisting  all  forms  of  treatment 
often  are  greatly  benefited  by  change  of  air  and  surroundings. 

The  chorea  of  pregnancy  should  be  treated  by  insisting  upon  rest  and 
quiet,  nutritious  food  and  good  nursing.  As  sedatives,  hydrated  chloral 
and  chloralamide  are  to  be  preferred  to  opium  or  the  bromides  and  the  arsenic 
prescribed  should  be  combined  with  alcohol,  the  latter  drug  being,  in  the 
opinion  of  certain  observers,  the  more  important  of  the  two.  It  is  seldom 
necessary  to  induce  labor  on  account  of  the  severity  of  the  chorea  and  spontan- 
eous abortion  as  a  result  of  the  affection  is  not  very  frequent. 

Chorea  due  to  sepsis,  puerperal  or  otherwise,  has  been  successfully  treated 
bv  intravenous  injections  of  collargol.  Two  to  five  drachms  (8.0-20.0)  of  a 
2  percent,  solution  may  be  injected  into  one  of  the  superficial  veins  of  the 
arm. 

CHOREIFORM  AFFECTIONS. 

These  occur  in  several  forms  and  may  be  described  as  convulsive  contrac- 
tures.    They  are  often  spoken  of  as  "tics"  or  "habit  spasms." 


CONVULSIVE    TIC.  819 

CONVULSIVE  TIC. 

Synonyms.     Habit  Spasm;  Habit  Chorea. 

This  condition  is  most  often  seen  in  children,  girls  particularly,  from  seven 
to  fourteen  years  of  age.  The  spasm  usually  affects  the  facial  muscles,  either 
a  single  one  or  a  group.  The  milder  types  consist  of  rapid  opening  and 
shutting  of  the  eyes,  drawing  the  mouth  to  one  side,  jerking  or  shaking  the 
head  while  the  eye  is  winked  at  the  same  time,  shrugging  one  shoulder  or 
sniffing. 

The  leg  muscles  are  more  rarely  involved  although  the  "string-half,  tic 
in  which  one  leg  is  suddenly  lifted  at  intervals,  may  occur.  These  affections 
are  rarely  permanent  although  at  times  they  may  persist  through  life.  They 
usually  disappear  gradually  in  a  few  months. 

Treatment  consists  in  the  removal  of  any  cause  of  irritation.  The  eyes 
and  nose  should  be  examined,  decayed  teeth  drawn,  etc.  General  tonics  and 
nerve  sedatives  are  indicated.  Otherwise  the  treatment  is  identical  with 
that  of  spasm  of  the  facial  nerve  (p.  803). 

IMPULSIVE  TIC. 

Synonym.     Gilles  de  la  Tourette's  Disease. 

This  affection  occurs  chiefly  in  children  of  neurotic  heredity.  More  rarely 
it  develops  after  the  age  of  puberty.  It  is  probably  best  considered  as  a 
psychosis  akin  to  hysteria  and  is  characterized  by  involuntary  movements 
involving  the  muscles  of  the  face  or  arms.  In  marked  instances  the  spasms 
may  be  general.  The  particular  characteristic  of  this  affection  is  the 
tendency  to  the  explosive  utterance  of  words  or  sounds  simultaneously  with 
the  movements.  A  sound  heard  may  be  repeated  numberless  times  (echolalia) 
or  the  patient  may  repeat  blasphemous  or  obscene  words  (coprolalia)  to  the 
great  distress  of  his  family  and  friends. 

Actions  may  be  imitated  (echokinesis).  There  may  be  mental  disorder 
characterized  by  fixed  ideas;  for  instance  the  patient  may  repeat  time  after 
time  names  which  he  hears  (onomatomania)  or  before  performing  a  certain 
act  may  count  a  certain  number  of  times  (arithmomania).  Another  mani- 
festation is  the  fear  of  contact  with  certain  objects  (delire  dii  toucher),  still 
another  is  to  require  a  reason  for  the  most  ordinary  acts  (folie  pourqjioi). 

Any  of  these  symptoms  may  occur  with  the  convulsive  movements  and  the 
latter  may  vary  from  slight  spasm  of  a  facial  muscle  to  contractions  affecting 
all  the  muscles  of  the  body.  The  condition  is  usually  easy  of  diagnosis,  the 
coprolalia  being  considered  its  most  characteristic  feature.  The  prognosis  is 
uncertain  but  patients  have  been  known  to  recover. 

The  treatment  is  chiefly  moral  and  occasionally  hypnotic  suggestion 
succeeds. 


820  DISEASES    or    THE    NERVOUS    SYSTEM. 

SALTATORY  SPASM. 

Latah;  Myriachit;  Jumpers;  Mali-mali. 

The  saltatory  spasm  is  a  condition  in  which  the  patient  is  affected  by  vigor- 
ous contractions  of  the  muscles  of  the  legs  which  occur  only  when  he  is  stand- 
ing. It  is  seen  in  individuals  of  neurotic  habit,  both  men  and  women;  the 
affection  may  be  transitory  or  persistent,  and  seems  closely  akin  to  the  latah 
of  the  Malays  and  mali-mali  of  the  Filipinos.  Amongst  the  Malay  race 
it  seems  to  chiefly  attack  women  who,  when  affected,  imitate  the  movements 
of  those  about  them  even  though  they  make  strong  efforts  to  desist;  echolalia 
may  co-exist  with  this  imitation  of  motion.  Heredity  seems  to  be  a  factor  in 
its  causation,  and  those  affected  by  it  are  subject  to  attacks  of  "  running 
amuck"  (see  p.  846).  The  myriachit  of  Russia  and  Siberia  and  the  jumpers 
of  the  Maine  woods  and  Canada  are  analogous  conditions.  Those  subject 
to  the  latter  disorder,  when  under  any  emotional  influence,  jump  violently  and 
cry  out;  they  may  obey  a  sharp  command  or  imitate  actions  or  sounds. 

CHRONIC  CHOREA. 

Synonyms.     Huntington's  Chorea;  Hereditary  Chorea. 

Definition.  A  chronic  disease  characterized  by  irregular  movements, 
speech  disturbance  and  gradually  increasing  dementia. 

.Etiology.  The  most  important  role  in  the  causation  of  this  disease  is 
played  by  heredity,  the  affection  having  been  observed  in  certain  families 
for  generations;  the  family  originally  reported  by  Huntington  in  1872  still 
exhibited  the  tendency  to  it  as  late  as  1898.  The  family  affected  is  usually  of 
neurotic  tendency  and  in  marked  instances  over  50  percent,  of  the  members 
are  affected.  The  disease  seldom  begins  earlier  than  the  age  of  thirty  and 
sex  seems  to  have  little  influence  in  its  causation.  Idiopathic  instances  have 
been  observed. 

Pathology.  This  affection  exhibits  no  typical  post  mortem  lesions,  although 
the  changes  which  are  usually  found  in  chronic  dementia — atrophy  of  the  cor- 
tex, meningo-encephalitis  and  changes  in  the  cerebral  vessels — are  often 
present.     It  is  probable  that  the  disease  is  in  no  way  akin  to  chorea  minor. 

Symptoms.  In  the  hereditary  form  of  the  affection  the  onset  is  usually 
sudden  with  irregular  movements  of  the  hands;  the  performance  of  fine  volun- 
tary movements  is  difficult.  Later  the  face  becomes  involved  and  the  gait 
is  disturbed.  The  movements  differ  from  those  of  chorea  minor  in  that  they 
are  slower,  more  irregular  and  lack  coordination.  The  gait  is  swaying,  the 
patient  may  seem  about  to  fall  and  then  by  an  effort  recover  just  as  an  intoxi- 
cated person  does.  The  movements  are  not  present  while  the  patient  is  at 
rest,  may  be  to  some  extent  controlled  by  the  will  and  are  increased  by  excite- 


EPILEPSY.  821 

ment.  The  speech  is  slow,  interrupted  and  indistinct;  writing  is  difficult 
at  first  and  later  impossible. 

Sensory  disorders  are  absent,  the  special  senses  and  muscular  sense  usually 
are  not  affected  although  the  latter  may  be  disturbed  late  in  the  disease. 

The  disorder  of  mentality  begins  as  a  depression"  and  an  irritability,  pass- 
ing to  feeble-mindedness  and  finally  to  complete  dementia.  Suicidal  tendency 
occurs  and  the  act  may  be  committed. 

The  disease  is  progressive  and  finally  fatal. 

Treatment  consists  merely  in  the  control  of  the  symptoms  as  they  arise. 
The  patient's  general  health  should  be  cared  for  by  prescribing  tonics,  nourish- 
ing food  and  a  life  in  the  open  air.  Nothing  can  be  done  to  arrest  the  progress 
of  the  disease. 

EPILEPSY. 

Synonyms.  FaUing  Sickness;  Morbus  Divinus;  Morbus  Astralis;  Morbus 
Sacer. 

Definition.  Epilepsy  is  a  chronic  functional  nervous  disease  characterized 
by  paroxysmal  seizures  typified  by  loss  of  consciousness  and  usually  by  con- 
vulsions. 

Jacksonian  epilepsy  is  characterized  by  recurrent  convulsions  affecting 
particular  groups  of  muscles  and  is  frequently  not  accompanied  by  loss  of 
consciousness. 

True  or  idiopathic  epilepsy  is  of  three  forms: 

1.  The  grand  nial,  the  most  severe,  in  which  the  convulsions  are  marked 
and  the  loss  of  consciousness  is  distinct. 

2.  The  petit  mal,  in  which  the  convulsions  and  unconsciousness  are  of 
trivial  character. 

3.  Psychical  epilepsy  which  is  characterized  by  mental  disorder  or  violent 
acts. 

.Etiology.  As  a  predisposing  cause  heredity  must  be  considered  to  exert 
the  most  definite  influence,  about  30  percent,  of  patients  showing  a  history  of 
mental  disease  or  epilepsy  in  the  family.  Other  predisposing  causes  are 
alcoholism,  consanguineous  marriage,  syphilis,  plumbism,  mental  disturb- 
ances during  pregnancy  and  traumatisms  during  parturition.  Sex  seems  to 
have  no  distinct  influence.  The  disease  usually  develops  between  the  ages 
of  ten  and  twenty,  although  it  may  appear  before  the  age  of  five.  After  twenty 
years  of  age  the  incidence  of  epilepsy  is  rare. 

Exciting  causes  are  rickets  in  infancy,  alcoholism,  syphilis,  head  injuries, 
the  acute  infectious  diseases  and  masturbation.  Reflex  causes  are  disorders 
of  the  genital  system  and  of  the  digestive  tract,  intestinal  parasites  and  consti- 
pation, and  ocular  and  aural  irritations. 


822  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Pathology.  The  pathology  of  true  idiopathic  epilepsy  is  unknown.  Lesions 
have  been  described  as  occurring  in  cases  in  which  a  syphilitic  element  is 
present  or  in  which  vascular  anomalies  exist,  but  in  epilepsy  in  which  such 
conditions  are  wanting,  no  constant  alterations  in  the  nervous  system  are 
found.  In  Jacksonian  epilepsy  distinct  abnormalities  are  present  such  as 
tumors,  localized  meningeal  thickenings  and  injuries  to  the  cranial  bones 
resulting  from  trauma. 

Physiology.  The  epileptic  paroxysm  is  to  be  considered  an  explosion  of 
nerve  energy,  the  seat  of  this  discharge  being  the  large  motor  cells  of  the 
cortex;  the  same  mechanism  is  responsible  for  paroxysms  of  psychical  epilepsy. 

Symptoms.  In  discussing  these,  the  four  chief  types  of  epilepsy  will  be 
taken  separately. 

I.  Grand  mal.  There  are  frequently  prodromal  symptoms  for  a  day  or 
for  only  an  hour  or  two  before  the  attack,  such  as  vertigo,  or  irritability.  In 
many  cases  the  paroxysm  is  ushered  in  by  a  peculiar  sensation  known  as  the 
aura.  This  may  be  a  wave-like  sensation  rising  from  the  feet,  involving  the 
body  and  when  it  reaches  the  head  the  convulsion  and  unconsciousness  occur. 
In  other  individuals  it  may  be  manifested  by  a  sensation  of  epigastric  dis- 
comfort; auditory  aurae,  such  as  the  hearing  of  voices  or  musical  sounds,  visual 
aurae  such  as  a  flash  of  light  or  color  or  the  appearance  of  objects  or  faces 
and  olfactory  or  gustatory  aurae  causing  sensations  of  smell  or  taste  are  not 
uncommon.  Accompanying  the  aura  and  the  onset  of  the  paroxysm  many 
patients  cry  out.  As  this  cry  is  uttered  the  patient  falls  and  the  first  or  tonic 
stage  of  the  attack  begins.  In  the  tome  spasm,  which  lasts  fifteen  or  twenty 
seconds,  the  head  is  drawn  back  or  to  the  side,  the  limbs  and  body  are  rigid, 
the  elbows  and  wrists  are  flexed,  the  hands  clenched  and  the  legs  and  feet 
extended,  respiration  ceases  and  the  face  becomes  swollen  and  cyanotic, 
the  neck  may  be  twisted  and  the  vertebral  column  curved.  The  clonic  spasm 
now  supervenes  and  is  characterized  by  convulsive  movements  of  the  face 
and  limbs,  the  latter  being  violently  flexed  and  extended;  the  facial  muscles 
are  involved,  the  eyeballs  roll  and  the  lids  open  and  shut;  saliva  collects  in 
the  mouth  and  is  churned  into  froth  by  the  contractions  of  the  muscles  of  the 
jaw,  the  froth  becoming  bloody  if  the  tongue  is  bitten.  The  urine  and  faeces 
may  be  passed  involuntarily;  the  cyanosis  becomes  less;  the  temperature  may 
rise  J  to  i°  F.  and  the  pulse,  weak  at  first,  becomes  rapid  and  tense;  later  as 
the  convulsions  abate  it  becomes  feeble  once  more.  This  stage  lasts  a  minute 
or  two,  gradually  subsides  and  the  patient  lapses  into  the  stage  of  coma. 
In  this  condition  the  muscles  are  relaxed,  the  respiration  is  stertorous,  the  face 
suffused  but  not  cyanotic.  The  coma  passes  into  a  slumber  which  may  last 
several  hours  after  which  the  patient  awakes  suffering  perhaps  from  headache 
or  confusion  of  mind,  or  on  the  other  hand  in  normal  condition  save  for  stiff- 
ness and  bruises. 


EPILEPSY.  823 

The  status  epilepticus  is  a  condition  in  which  the  unfortunate  patient 
passes  from  convulsion  to  convulsion  for  hours  or  days,  never  regaining  con- 
sciousness; later  the  convulsions  are  replaced  by  coma,  or  more  rarely  mania, 
and  the  patient  dies  of  exhaustion. 

After  an  epileptic  seizure  the  reflexes  may  be  lost;  at  times  they  are  exag- 
gerated; there  may  be  slight  temporary  glycosuria  or  albuminuria;  the  red 
cells  of  the  blood  and  the  haemoglobin  are  diminished. 

2.  Petit  mal.  In  this  form  there  is  rarely  an  aura  or  a  cry,  the  attack  lasts 
but  a  few  seconds,  the  patient  stops  suddenly  whatever  he  may  be  doing, 
the  features  become  set,  the  eyes  open  widely  and  are  set,  the  pupils  dilate, 
there  may  be  slight  muscular  twitchings  and  consciousness  is  lost  for  the 
moment  and  he  may  fall.  The  attack  is  over  after  a  few  seconds  and  the 
patient  resumes  his  former  occupation  conscious  merely  that  he  has  suffered 
from  a  "spell."  At  times  he  may  turn  about,  take  a  few  steps  or  perform 
forced  movements — procursive  epilepsy.  Seizures  of  petit  mal  may  alternate 
with  those  of  grand  mal  and  as  the  disease  continues  the  attacks  increase  in 
intensity  and  they  rnay  become  entirely  of  the  grand  type. 

3.  Jacksonian  epilepsy.  This  type  of  the  disease  is  not  characterized  by 
loss  of  consciousness.  The  convulsion  affects  a  single  group  of  muscles  or 
a  limb.  It  is,  as  a  rule,  the  result  of  a  focal  lesion  of  the  motor  area  of  the 
cerebral  cortex  such  as  a  tumor,  disease  or  injury.  The  attack  begins  with 
numbness,  tingling  sensations  or  muscular  contraction  (Seguin's  sign)  in  the 
part  to  be  attacked;  the  convulsions  begin  always  in  the  same  part,  a  finger, 
a  toe  or  the  face.  The  movements  are  tonic  and  clonic  extending  in  regular 
order,  for  instance  from  a  finger,  to  the  hand  and  thence  throughout  the 
arm.  After  the  attack  the  affected  part  may  be  numb  or  partly  paralyzed  and 
loss  of  tactile  or  temperature  sense  may  be  present.  The  situation  in  which 
the  seiztire  begins  is  important  in  determining  the  localization  of  the  brain 
lesion  and  in  fixing  the  site  for  operative  intervention. 

4.  Psychical  epilepsy  follows  petit  mal,  more  rarely  grand  mal  or,  occur- 
ring independently,  is  considered  a  "psychical  epileptic  equivalent."  During 
the  paroxysm  the  patient  may  exhibit  mental  violence,  or  perform  extravagant 
acts,  sometimes  criminal  in  character.  Accustomed  acts  may  be  performed 
during  a  somnambulistic  condition  which  at  times  occurs  in  place  of  the 
ordinary  seizure;  these  are  often  complicated  and  include  driving,  walking, 
etc.  Abortive  attacks  of  psychical  epilepsy  lasting  but  a  few  seconds  and 
consisting  of  a  short  tonic  and  a  very  mild  clonic  stage  are  sometimes  seen. 

Grand  mal  is  the  type  of  the  disease  most  frequently  observed,  next  in  order 
comes  the  mixed  type  while  petit  mal  is  still  less  common.  Jacksonian  and 
psychical  epilepsy  are  rarest  of  all. 

During  the  developmental  stage  of  the  disease,  major  attacks  may  occur 
only  two  or  three  times  a  year.     Gradually,  however,  they  increase  in  fre- 


824  DISEASES    OF    THE    ISTERVOUS    SYSTEM. 

quency  until  they  may  take  place  even  several  times  a  month.  In  very  severe 
instances  there  may  be  daily  attacks.  Frequent  seizures  of  petit  trial  are  the 
rule;  their  daily  incidence  is  not  at  all  uncommon. 

The  most  usual  time  of  day  for  epileptic  attacks  is  between  8  A.M.  and 
8  P.M.  and  a  not  infrequent  time  is  early  in  the  morning  when  the  vital  forces 
are  at  their  lowest  ebb.  Nocturnal  seizures  are  not  rare.  Between  the 
attacks  the  patient  feels  well,  indeed  a  nervous  explosion  may  be  followed 
by  a  distinct  improvement  in  his  condition. 

The  prognosis.  This  is  best  as  regards  recovery  in  patients  with  infrequent 
attacks.  When  the  seizures  are  altogether  during  the  day  or  at  night  the 
prognosis  is  better  than  in  the  mixed  type.  When  the  disease  begins  after 
twenty  years  of  age  the  chances  of  recovery  are  better  than  in  instances  commenc- 
ing earlier  in  life.  While  epileptic  patients  seldom  die  of  the  disease,  their  lives 
seem  to  be  shortened  by  it  and  recovery  is  rather  rare;  about  lo  percent,  of 
instances  result  in  insanity  or  dementia. 

Of  the  different  types  of  epilepsy  the  prognosis  is  worst  in  the  psychical 
variety,  better  in  petit  mat  and  most  favorable  in  grand. nial. 

Treatment.  Prophylaxis:  Neurotic  children  who  have  convulsions  in 
infancy  should  command  our  best  efforts  to  learn  the  cause  of  this  manifes- 
tation, to  remove  it  and  to  advise  such  an  education  and  training  as  will 
result  in  both  physical  and  mental  health.  Such  children,  when  under  the 
influence  of  a  neurotic  father  or  mother,  often  do  better  when  brought  up 
away  from  home. 

Before  beginning  treatment  a  thorough  investigation  of  the  patient  should  be 
made  in  order  to  ascertain  whether  the  condition  is  or  not  due  to  peripheral 
irritation.  The  blood,  the  urine  and  the  fasces  should  be  examined,  the  eyes 
should  be  investigated  for  evidences  of  eye-strain,  the  ears,  nose,  and  mouth 
for  signs  of  reflex  irritation,  the  genitals  for  evidence  of  phimosis  or  masturba- 
tion; the  digestive  tract  should  be  rendered  as  normal  in  its  action  as  possi- 
ble; gastric  atony,  intestinal  fermentation  and  constipation  deserve  especial 
attention. 

Another  most  important  consideration  is  to  institute  treatment  as  early 
after  the  incidence  of  the  disease  as  possible  and  to  carry  it  out  vigorously. 
Particularly  should  children  who  have  had  convulsions  in  early  life  receive 
careful  attention  and  should  the  seizures  be  recognized  as  epilepsy,  treatment 
should  be  continued  for  at  least  three  years  after  the  last  attack  has  been 
observed. 

Constitutional  treatment  with  the  view  of  absorbing  or  preventing  sclerotic 
patches  in  the  nervous  system; — such  deposits  having  been  observed  in  many 
cases — may  be  instituted.  Here  the  alteratives,  arsenic,  mercury,  sodium  and 
gold  chloride  and  potassium  iodide,  are  indicated;  if  a  syphilitic  element  is 
present  appropriate  treatment  is  necessary.    Cases  in  which  there  are  co-exist- 


EPILEPSY.  825 

ent  lithaemic  or  purinasmic  conditions  sometimes  may  be  relieved  by  the  use  of 
saligenin  tannate,  gr.  xv  (i.o)  three  times  daily  with  the  alkalies  and  proper 
diet  as  adjuvants.  Circulatory  and  vaso-motor  disorders,  which  are  not 
rare,  may  be  combated  by  strychnine  and  other  heart  tonics  and,  in  conditions 
of  hypertension,  by  glyceryl  nitrate. 

In  the  specific  treatment  of  epilepsy  the  bromides  are  the  most  useful 
remedies  but  are  not  without  disadvantages.  The  most  effectual  of  these 
are  potassium  bromide,  sodium,  strontium,  rubidium  and  ammonium  bro- 
mides and  hydrobromic  acid.  While  the  action  of  all  these  agents  is  similar 
the  potassium  salt  seems  to  be  most  effectual;  at  times  it  may  be  of 
benefit  to  the  stomach  or  otherwise  of  advantage  to  change  from  one  to 
another  or  to  administer  a  mixture  of  several  of  the  salts.  Sodium  bromide 
is  less  unpleasant  to  the  taste  than  potassium  bromide  and  less  disturbing  to 
the  digestion;  ammonium  bromide  is  slightly  stimulating  to  the  heart.  Hydro- 
bromic acid  may  be  given  when  the  alkaline  salts  are  disturbing  to  the  alimen- 
tary tract;  the  bromide  eruption  is  less  likely  to  follow  its  use  than  that  of 
the  bromides. 

The  dosage  employed  should  be  sufficient  to  control  the  paroxysms,  begin- 
ning at  about  15  grains  (i.o)  four  times  daily  and  gradually  increased  until 
effectual.  As  much  as  2  drachms  (8.0)  four  times  a  day  has  been  given; 
this  amount  produces  bromism  but,  when  necessary  to  suppress  the  attacks, 
may  be  employed,  always  with  care,  however,  as  harm  sometimes  results. 
The  seizures  having  ceased,  the  dosage  should  be  lessened,  but  the  treatment 
should  be  continued  for  a  couple  of  years  at  least.  Nocturnal  epilepsy  may 
sometimes  be  controlled  by  a  single  large  dose  given  at  bedtime  but  as  a 
general  rule  the  drug  is  best  given  on  an  empty  stomach  either  a  little  while 
before  meals  or  two  or  three  hours  after. 

The  disadvantage  of  the  bromide  treatment  is  the  likelihood  of  causing 
bromism  which  is  manifested  by  drowsiness  and  hebetude,  digestive  disorders, 
cardiac  distress  and  the  typical  bromide  acne.  It  is  difficult  to  mitigate  these 
unpleasant  symptoms  unless  the  drug  is  stopped;  the  most  approved  measures 
to  prevent  their  occurrence  are  the  employment  of  salt  water  baths,  massage 
and  regular  exercise  with  the  administration  of  the  bitter  tonics,  iron,  cod- 
liver  oil  and  the  mineral  acids.  The  acne  may  be  prevented  by  the  adminis- 
tration of  arsenic,  the  unpleasant  bromide  eructations  by  combining  the 
bromide  with  an  alkali,  though  this  may  disturb  the  bladder;  this  distiirbance 
may  be  relieved  by  giving  the  bromide  in  hydrobromic  acid.  The  best 
method  of  taking  the  bromides  is  in  carbonic  or  Vichy  water  in  proportion  of 
about  ^  drachm  (2.0)  to  a  glassful. 

In  some  instances,  especially  those  in  which  the  drug  causes  digestive  disturb- 
ance, the  bromides  are  ineffectual ;  in  these  obstinate  cases  they  may  be  combined 
with  solanum  carolinense  (the  fluidextract,  |  to  2  drachms — 2.0  to  8.0 — three 


826  DISEASES    OF    THE    NERVOUS    SYSTEM. 

or  four  times  daily)  and  for  patients  whose  intolerance  to  the  bromides  neces- 
sitates their  omission,  this  drug  alone  may  be  prescribed. 

It  is  said  that  if  the  sodium  chloride  of  the  diet  is  restricted  or  omitted 
entirely  the  bromides  will  prove  more  effectual  and  smaller  doses  may  be 
employed. 

Hydrated  chloral  and  chloralamide  are  useful  adjuncts  to  the  bromides 
but  should  be,  especially  the  former,  given  with  care.  Five  to  ten  grains  (0.33- 
0.66)  of  chloral  may  be  combined  with  a  diminished  amount  of  bromide  and 
given  with  good  effect.  Another  combination  which  is  deserving  of  trial  is 
one  of  antipyrine,  6  grains  (0.40)  and  ammonium  bromide,  10  grains  (0.66) 
given  tliree  times  a  day.  Acetanilide  may  prove  useful  as  also  may  mono- 
bromated camphor  in  doses  of  5  grains  (0.33). 

Other  drugs  which  have  enjoyed  vogue  in  the  treatment  of  epilepsy  and 
may  be  substituted  for  the  bromides  are  the  tincture  of  capparis  coriacea, 
I  drachm  (4.0)  four  times  a  day,  belladonna,  zinc  iodide  and  oxide,  sodium 
borate,  sulphonmethane  and  valerian. 

In  petit  mal  glyceryl  nitrate  given  to  the  physiological  limit  is  of  service.  Its 
dosage  varies  with  the  tolerance  of  the  patient  from  j^q-  to  2T  o^  ^  grain 
(0.0006-0.0024).  The  bromides  also  are  useful  and  antipyrine,  belladonna, 
cannabis  indica,  ergot  and  general  tonic  treatment  may  be  employed. 

The  treatment  of  the  seizure.  The  patient  whom  an  aura  warns  of  a 
coming  attack  is  fortunate,  for  in  amyl  nitrite  we  have  a  fairly  efficient  means 
of  preventing  its  onset.  This  drug  may  be  carried  in  the  pocket  in  the  form 
of  "  pearls"  or  in  a  small  bottle;  the  former  may  be  broken  at  the  appropriate 
time  and  the  contents  inhaled.  Other  methods  of  aborting  a  paroxysm 
are  the  inhalation  of  ammonia  or  chloroform,  pressure  over  the  carotid  arteries, 
the  internal  administration  of  alcohol  or  aromatic  ammonia  spirit.  Brower 
reports  a  patient  whose  aura  began  in  the  hand;  about  the  wrist  he  wore  a 
noose  of  thread  which,  when  the  warning  appeared,  he  would  tighten,  thus 
stopping  the  progress  of  the  paroxysm. 

During  the  attack  the  patient  should  be  prevented  from  doing  himself  injury 
and  some  such  object  as  a  spool,  a  bit  of  wood  or  a  roller  bandage  should  be 
inserted  between  the  teeth  to  prevent  biting  of  the  tongue. 

The  status  epilepticns  should  be  combated  by  hydrated  chloral  given  per 
rectum  and  the  stomach  and  bowels  should  be  emptied  by  lavage  or  by  emetics 
and  purges.     Bleeding  may  be  employed. 

The  treatment  of  epileptics  at  special  institutions  or  colonies  is  strongly  to 
be  advocated.  Here  the  mode  of  life  may  be  properly  regulated,  the  mind 
of  the  patient  may  be  kept  congenially  occupied  and  physical  work  within 
proper  limits  prescribed. 

Hydrotherapy.  Systematic  hydrotherapeutic  measures  are  a  useful  adjunct 
to  treatment ;  under  their  employment  there  is  less  likelihood  of  inducing  brom- 


MYOTONIA   CONGENITA.  827 

ism  and  causing  acne.  By  increasing  the  eliminative  process  of  the  organism 
as  well  as  by  the  stimulating  and  tonic  effect,  the  tolerance  for  the  bromide  is 
increased  and  its  toxic  power  diminished.  For  a  patient  accustomed  to  a  cold 
morning  tub  this  measure  may  be  prescribed,  otherwise  he  may  be  given  a 
dry  or  alcohol  rub  before  rising;  later  the  cold  packs  followed  by  a  vigorous 
rubbing  are  admissible;  when  the  patient's  condition  permits,  a  hip  bath  be- 
ginning at  90°  F.  (32.2°  C.)  and  lasting  five  minutes  may  be  given,  the  tempera- 
ture being  reduced  one  degree  per  day,  until  80°  F.  (26.1°  C.)  is  reached. 
Another  useful  procedure  is  the  douche.  Both  this  and  the  hip  bath  should 
be  followed  by  vigorous  rubbing  by  an  attendant.  Other  balneo-therapeutic 
measures  will  undoubtedly  suggest  themselves  as  indications  arise. 

Jacksonian  epilepsy  may  often  be  traced  to  head  injuries  and  in  cases  of 
this  type  there  is  possibility  of  cure  by  removal  of  pressure  upon  the  brain 
by  surgical  means.     In  other  forms  of  epilepsy  surgery  can  be  of  no  benefit. 

Diet.  The  dietetics  of  this  disease  is  most  important  and  the  fact  that 
this  element  in  the  management  of  epilepsy  can  be  properly  regulated  in 
institutions  is  a  strong  point  in  favor  of  the  employment  of  this  form  of  treat- 
ment. The  restriction  of  salt  is  a  distinct  advance  in  the  treatment  of  this 
condition.  The  patient  soon  learns  to  do  without  sodium  chloride  and 
equally  readily  accustoms  himself  to  the  use  of  sodium  bromide  in  its  stead, 
and  even  may  prefer  it.  The  diet  itself  should  consist  of  plain,  nourishing 
and  easily  digested  foods.  Starchy  indigestion  should  be  avoided  by  guard- 
ing against  a  too  exclusively  vegetable  regimen.  For  breakfast  the  patient 
may  have  fruit,  a  cereal,  eggs,  toast,  rolls  or  biscuit  and  milk,  buttermilk, 
or  cocoa;  at  dinner  a  puree  or  clear  soup  is  allowable,  with  fish,  meat  or  fowl, 
vegetables  and  a  simple  salad,  and  fruit,  plain  puddings  or  ice  cream  as 
dessert.  Supper  may  consist  of  bread  or  rolls,  cold  meat,  oysters,  sweet- 
breads or  calf's  brain  and  stewed  fruit,  with  milk  or  cocoa. 

Alcohol,  tobacco,  tea  and  coffee,  sweets,  fried  foods  and  rich  made  dishes 
should  be  avoided. 

MYOTONIA  CONGENITA. 

Synonym.    Thomsen's  Disease. 

Definition.  A  disease  characterized  by  hypertrophy  of  the  muscles  and  by 
tonic  cramp  on  attempting  voluntary  movement. 

.Etiology.  Myotonia  congenita  is  an  hereditary  affection  appearing,  in  all 
typical  cases,  in  early  childhood  and  in  certain  famihes.  It  had  appeared  in 
the  family  of  its  first  describer,  Thomsen,  for  five  generations.  Males  are 
much  more  frequently  affected  than  females  and  the  disease  is  more  frequent 
in  Scandinavia  and  Germany  than  in  England  or  America.  The  instances  of 
acquired  myotonia  seem  to  differ  somewhat  from  Thomsen's  disease. 


825  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Pathology.  The  muscles,  especially  those  of  the  limbs,  are  larger  than 
normal  and  may  be  the  seat  of  a  true  hypertrophy;  they  are,  however,  much  less 
powerful  than  their  appearance  would  imply.  Microscopically  the  muscle 
fibres  are  sometimes  enlarged  and  their  nuclei  increased,  although  the  results 
of  late  research  seem  to  show  that  this  enlargement  is  not  characteristic  of  the 
disease;  the  intra-muscular  connective  tissue  maybe  increased  and  degenerative 
and  regenerative  changes  have  been  observed.  The  theory  has  been  advanced 
that  the  condition  is  the  result  of  an  autointoxication  of  the  muscular  tissue 
due  to  disordered  metabolism. 

Symptoms.  The  onset  of  the  disease  occurs  in  childhood  and  is  first  evi- 
denced by  a  muscular  stiffness  which  causes  a  delay  in  voluntary  movement. 
There  is  no  paralysis  and  when  a  movement  is  begun  it  is  carried  out.  Rapid 
and  accurate  movement  is  impossible  and  a  contraction  may  persist  after 
its  end  has  been  accomplished.  The  arms  and  legs  are  chiefly  affected; 
the  gait  is  disturbed,  in  that  there  is  a  hesitancy  at  the  start,  after 
a  few  steps  there  is  no  difficulty  in  continuing.  The  condition  is  accentuated 
by  excitement  or  cold.  Rarely  the  muscles  of  the  face,  eye  or  larynx  may 
be  affected. 

There  is  no  abnormality  of  sensation  or  of  the  reflexes;  the  so-called  myotonic 
reaction  of  Erb  is  present  and  is  characteristic  of  this  condition,  the  galvanic 
and  faradic  irritability  of  the  motor  nerves  being  quantitatively  normal  and 
short  contractions  result  from  briefly  acting  stimuli.  With  continuous  excita- 
tion by  either  current  the  contractions  slowly  reach  their  maximum  and 
slowly  relax,  while  vermicular,  wave-like  contractions  pass  from  cathode  to 
anode. 

There  is  no  atrophy  or  considerable  loss  of  power  except  in  so  far  as  the 
stiffness  interferes  with  movement. 

The  disease  resists  treatment  but  the  patients  are  often  able  to  educate 
themselves  so  that  the  disability  is  but  slightly  noticeable. 

Treatment  consists  merely  in  attention  to  the  general  health  and  the  employ- 
ment of  massage  and  gymnastic  exercises. 

PARAMYOCLONUS  MULTIPLEX. 

Definition.  A  disease  characterized  by  clonic  contractions  of  various 
groups  of  muscles,  usually  of  the  extremities,  occurring  either  in  paroxysms 
or  constantly. 

Etiology.  Little  is  known  of  the  causation  of  this  condition.  Heredity 
seems  to  be  a  factor  in  that  many  patients  give  a  family  history  of  various  types 
of  nervous  disease.  It  is  a  disease  of  adult  life  and  is  more  often  observed  in 
the  male  sex.     It  has  been  known  to  follow  emotional  disorders  and  fright. 


PARALYSIS    AGITANS.  829 

Pathology.  The  morbid  anatomy  of  paramyoclonus  multiplex  is  still 
undiscovered. 

Symptoms.  The  most  marked  symptom  is  the  occurrence  of  clonic 
contractions  involving  chiefly  the  muscles  of  the  limbs  and  trunk,  rarely  those 
of  the  face.  They  are  bilateral,  as  a  rule,  sudden,  and  as  many  as  150  per 
minute  may  take  place.  Tonic  spasms  have  also  been  observed.  The  con- 
tractions are  increased  by  emotional  states,  are  diminished  by  voluntary 
movement  and  are  absent  during  sleep.  At  times  the  patient  may  emit  a 
grunting  sound  which  perhaps  is  due  to  involvement  of  the  larynx  and  dia- 
phragm. Between  paroxysms  there  may  be  muscular  tremors.  In  marked 
types  of  the  disease  the  movements  may  be  very  violent  and  the  patient  may  be 
with  difficulty  kept  in  bed.  There  are  no  mental,  sensory  or  trophic  symp- 
toms and  the  electric  reaction  of  the  muscles  is  unchanged,  though  an  electric 
stimulus   may   incite  a   paroxysm.     The   tendon  reflexes  are   exaggerated. 

The  prognosis  with  regard  to  complete  recovery  is  poor,  the  condition 
usually  persisting  for  a  number  of  years,  although  it  may  prove  fatal  within  a 
few  months. 

Treatment  consists  in  the  employment  of  measures  calculated  to  improve 
the  general  health,  tonics,  out-of-door  life,  nourishing  food,  etc.  All  possible 
excitement  must  be  avoided.  Arsenic,  iron  and  phosphorus  may  be  given 
and  a  course  of  hydrotherapy  at  a  suitable  institution  may  prove  beneficial. 
The  marked  paroxysms  of  the  severe  t}-pes  of  the  disease  may  necessitate  the 
hypodermatic  administration  of  morphine. 

PARALYSIS  AGITANS. 

Synonyms.     Shaking  Palsy;  Parkinson's  Disease. 

Definition.  A  chronic  nervous  affection  characterized  by  muscular  tremors, 
weakness  and  rigidity. 

.Etiology.  The  causation  of  this  disease  is  obscure.  It  occurs  most  often 
in  individuals  belonging  to  families  in  which  other  nervous  diseases  have 
appeared,  is  usually  seen  after  the  age  of  forty  and  is  more  common  in  males 
than  in  females.  It  may  follow  malaria  and  other  infectious  diseases  and  is 
predisposed  to  by  alcoholism  and  sexual  excess.  Of  exciting  causes,  exposure 
to  cold,  injuries,  worry  and  mental  over-exertion  may  be  mentioned. 

Pathology.  There  is  no  characteristic  lesion  but  the  disease  is  probably 
the  result  of  some  change  in  the  cerebral  cortex.  The  theory  has  been  ad- 
vanced that  it  is  due  to  premature  senile  changes  in  the  brain.  Dana  suggests 
that  in  paralysis  agitans  there  is  destruction  and  degeneration  of  the  dendrites 
of  the  cells  of  the  anterior  cornua  of  the  cord  interfering  with  the  even  progress 
of  motor  impulses,  leading  finally  to  motor  weakness  and  rigidity,  owing  to 


830  DISEASES    OF    THE    NERVOUS    SYSTEM. 

severence  of  the  connection  between  these  cells  and  the  brain,  these  mani- 
festations having  been  preceded  by  a  functional  disturbance.  According  to 
Gordinier  the  primary  change  is  in  the  blood-vessels,  later  it  spreads  to  the 
adjacent  neuroglia  and  results  in  patches  of  peri-vascular  sclerosis;  the  abnor- 
malities which  have  been  observed  in  the  anterior  horn  cells  and  in  those  of 
the  motor  cortex  being  due  to  diminished  nutrition  dependent  upon  the 
vascular  changes. 

Symptoms.  Of  these  tremor,  either  constant  or  intermittent,  and  usually 
first  affecting  the  hands,  is  earliest  noted.  The  onset  of  the  disease  is  slow 
as  a  rule  although  it  may  develop  suddenly  after  exposure,  trauma  or  emotion. 
The  tremor  of  the  hands  is  characterized  by  movements  of  forefinger  and 
thumb  resembling  those  made  in  rolling  a  pill;  rotation  and  tremor  of  the 
forearm  is  also  present.  The  arm  is  seldom  affected  and  the  movements  of 
the  lower  limbs  are  most  marked  at  the  ankle  joints.  There  may  be  nodding 
movements  of  the  head.  The  movements  at  first  are  absent  during  sleep 
but  finally  remain  present  at  all  times.  By  an  effort  of  will  the  patient  may 
check  the  tremor  but  it  returns,  often  exaggerated  in  degree.  It  is  increased 
by  excitement  or  emotion  but  may  cease  in  states  of  excessive  rigidity. 

The  accompanying  muscular  weakness  is  present  in  greater  or  less  degree 
and  is  most  apparent  when  the  tremor  is  marked.  Entire  loss  of  muscular 
power  is  rare. 

The  rigidity  is  evidenced  by  impairment  of  activity,  movement  is  stiff  and 
retarded.  This  symptom  is  progressive  and  results  in  the  attitude  typical 
of  the  disease.  Here  the  head  and  body  are  bowed,  the  elbows  are  flexed 
and  held  away  from  the  body;  the  knees  may  interfere  in  walking  and  the 
patient  may  seem  about  to  fall  forward.  He  walks  with  eyes  upon  the  ground 
before  him  and  takes  quick,  short  steps,  acting  as  if  he  were  about  to  fall  for- 
ward and  were  endeavoring  to  prevent  this  calamity  by  continually  changing 
his  center  of  gravity.  If  pushed  backward  he  is  likely  to  fall  being  unable 
to  maintain  his  balance.  The  facial  appearance  is  changed,  being  expressionless 
and  mask-like  (Parrot's  sign).  Saliva  may  dribble  from  the  partly  open  mouth 
or  if  this  is  kept  closed,  it  may  be  found  full  of  this  secretion  owing  to  delayed 
deglutition.  The  voice  may  be  high-pitched  and  the  speech  slow,  though  if 
the  lips  and  tongue  are  involved  in  the  tremor,  the  patient  may  stammer.  The 
reflexes  remain  unaltered  or  rarely  are  exaggerated.  There  may  be  altered 
temperature  sense  but  otherwise  there  is  no  sensory  abnormality.  The 
skin  may  be  thickened,  particularly  that  of  the  forehead,  it  may  flush  easily 
or  perspire  excessively.  The  temperature,  bowels  and  bladder  are  unaffected 
but  there  may  be  areas  of  heightened  surface  temperature. 

The  prognosis.  The  course  of  the  disease  is  slow  and  gradual  and,  while 
periods  of  intermission  may  occur,  its  progress  is  continually  downward; 
it    lasts    for    years,   the    patient    usually  dying  from    intercurrent  disease. 


INFANTILE    ECLAMPSIA.  831 

Treatment  directed  to  the  arrest  of  the  condition  is  unavaihng,  consequently 
we  can  do  little  except  to  care  for  the  patient's  general  health  by  the  adminis- 
tration of  proper  food  and  tonics.  Fresh  air,  exercises,  electricity,  massage 
and  warm  bathing  are  indicated. 

With  regard  to  drugs,  hyoscine  hydrobromide  in  doses  of  gr.  y^-j  to  y^^ 
(0.0005-0.0006)  or  atropine,  grains  j^-^  to  -^\  (0.0006-0.001)  may  be  given 
hypodermatically  two  or  three  times  a  day,  depending  upon  the  severity  of 
the  symptoms,  and  duboisine,  opium,  arsenic,  and  potassium  iodide  may  be 
tried.  Hot  moist  or  dry  compresses  may  be  applied  to  the  muscles  if  these 
are  painful  and  if  hyperexcitability  of  the  nervous  system  is  present,  the 
bromides  and  hydrated  cliloral  may  be  employed  with  benefit. 

ECLAMPSIA. 

This  term  is  applied  to  reflex  convulsions  occurring  in  children  and  to  the 
convulsions  of  the  puerperal  state  in  women. 

INFANTILE  ECLAMPSIA. 

Synonyms.     Infantile  Convulsions;  Epilepsia  Acuta. 

Definition.     Convulsions  due  to  peripheral  reflex  irritation. 

^Etiology.  Convulsions  in  children  may  result  from  very  slight  causes, 
usually  reflex  in  character  and  due  as  a  rule  to  digestive  disorders,  such  as 
inflammations,  intestinal  parasites,  foreign  bodies,  fascal  accumulations, 
vesical  calculi,  rickets,  nepliritis,  and  the  infectious  fevers.  Children  of 
neuropathic  heredity  are  prone  to  exhibit  this  manifestation  and  it  is  the 
result  of  a  hyperexcitable  state  of  the  nerve  centers  permitting  sudden,  excessive 
and  transient  discharges  of  nerve  force. 

Symptoms.  The  seizure  may  vary  from  mere  twitching  or  clinching  of  the 
fingers  to  marked  convulsive  paroxysms  closely  resembling  those  of  epilepsy 
(see  p.  822).  The  attack  may  be  single  but  often  several  convulsions  may 
appear  following  one  another  at  intervals  of  hours  or  days.  Rarely  does 
the  seizure  end  in  death.  Frequently  repeated  convulsions  may  induce  the 
"convulsive  habit"  and  from  this  epilepsy  may  result. 

The  attack  may  appear  without  prodromal  symptoms  or  it  may  be  pre- 
ceded by  malaise  and  restlessness.  The  seizure  is  often  accompanied  by 
rise  in  temperature. 

The  prognosis  of  infantile  convulsions  depends  upon  the  causative  factor 
and  the  age  of  the  patient.  Life  is  seldom  endangered  except  in  very  young 
infants  and  in  rhachitic  patients.  Permanent  brain  impairment  is  rare  but  may 
occur.  Convulsions  at  the  onset  of  an  infectious  disease  are  rarely  fatal  and 
may  not  augur  a  severe  type  of  the  infection.     Nephritic  convulsions  are 


532  DISEASES    OF    THE    NERVOUS    SYSTEM. 

serious  and  in  those  of  whooping  cough  and  of  asphyxia,  the  worst  is  to  be 
anticipated. 

Treatment.  The  child  suffering  from  convulsions  should  be  kept  perfectly 
quiet.  The  mustard  bath  is  better  omitted  and  a  mustard  pack  substituted. 
The  latter  is  made  by  adding  to  one  quart  of  tepid  water  a  tablespoonful  of 
mustard;  a  towel  is  wet  in  this  and  while  dripping  is  wrapped  about  the  patient's 
body;  outside  this  a  blanket  is  wrapped  and  he  is  allowed  to  lie  in  it  for  ten  to 
fifteen  minutes.  At  the  end  of  this  time  the  skin  should  be  well  reddened. 
The  pack  may  be  repeated  at  intervals  as  indicated.  Cold  compresses  should 
be  applied  to  the  head.  If  the  convulsion  is  of  severe  type,  chloroform  suffi- 
cient to  control  it  should  be  administered  and  at  the  same  time  an  enema  of 
hydrated  chloral  dissolved  in  an  ounce  (30.0)  of  warm  milk  should  be  given. 
A  child  of  six  months  may  receive  4  grains  (0.26),  a  child  of  one  year  6  grains 
(0.4).  This  should  be  injected  through  a  soft  catheter  passed  high  into  the 
rectum,  the  buttocks  being  held  together  to  prevent  its  discharge.  If  neces- 
sary the  dose  may  be  repeated  in  an  hour.  When  the  convulsions  persist 
after  the  chloroform  is  stopped  and  in  spite  of  the  hydrated  chloral,  morphine 
should  be  administered  hypodermatically.  To  a  child  of  six  months  jj 
of  a  grain  (0.0014)  may  be  given;  to  one  of  one  year  21  of  a  grain  (0.0025), 
to  be  repeated  in  one-half  to  one  hour  if  necessary.  If  the  heart  is  weak 
chloroform  may  be  contra-indicated  but  morphine  may  be  given.  Oxygen 
inhalations  may  relieve  the  condition,  especially  in  states  of  asphyxia  when 
other  treatment  is  of  no  avail. 

The  convulsions  being  under  control  it  remains  to  prevent  their  recurrence. 
This  is  accomplished  by  continuing  the  administration  of  hydrated  chloral  in 
diminishing  doses,  with  the  addition  of  sodium  bromide,  or  if  the  former 
is  not  well  borne  by  stomach  or  rectum,  antipyrine  or  acetphenetidine  in  small 
doses  may  be  substituted.  In  addition  to  the  above  treatment  the  gastro- 
intestinal tract  should  be  cleared  of  all  possible  irritant  material  by  the  admin- 
istration of  J  to  ^  a  grain  (0.016-0.032)  of  calomel  every  half  hour  up  to  six 
doses  and  by  thorough  washing  out  of  the  colon  by  means  of  a  soft  catheter 
and  warm  normal  saline  solution. 

The  further  treatment  consists  in  the  regulation  of  the  patient's  food  and 
mode  of  life,  together  with  appropriate  medication  for  the  underlying  condition. 

PUERPERAL  ECLAMPSIA. 

The  actual  causation  of  this  condition  is  not  definitely  known  but  it  undoubt- 
edly is  the  result  of  a  toxaemia  due  to  faulty  metabolism  and  elimination.  It 
is  often  associated  with  the  albuminuria  of  pregnancy  although  it  is  by  no 
means  certain  that  renal  lesion  is  its  causation.     The  convulsions  are  usually 


TETANY,  833 

preceded  by  a  feeling  of  fulness  in  the  head,  dizziness  and  arterial  hyperten- 
sion and  may  occur  either  before  or  after  the  uterus  is  emptied,  usually  how- 
ever, before  that  event.  The  convulsions  are  both  tonic  and  clonic  and  the 
condition  is  one  which  jeopardizes  the  life  of  the  patient,  consequently  all 
possible  measures  should  be  taken  toward  its  prevention  by  frequent  urine 
examination  during  the  later  months  of  pregnancy  and  careful  watching 
on  the  part  of  both  patient  and  physician  for  premonitory  symptoms. 

Treatment.  This  consists,  if  the  convulsions  appear  before  the  birth  of 
the  foetus,  in  emptying  the  uterus  as  rapidly  as  possible.  The  treatment 
for  the  convulsion  itself  is  to  be  carried  out  by  the  administration  of  chloro- 
form and  the  employment  of  other  means  applicable  to  such  conditions. 
If  the  arterial  tension  is  excessive  and  cyanosis  is  present,  venesection  and  the 
withdrawal  of  a  considerable  amount  of  blood  should  be  practiced,  the  fluid 
withdrawn  being  replaced  by  the  injection  of  an  equal  or  larger  amount  of 
normal  saline  solution  either  directly  into  the  vein  or  into  the  muscular  tissues 
of  the  thighs  or  buttocks.  The  drug  most  likely  to  be  of  service  is  veratrum 
and  it  is  best  given  hypodermatically  in  the  form  of  the  tincture,  30  to  40 
minims  (2.0-2.66)  and  repeated  until  the  arterial  tension  has  been  reduced  to 
normal  limits. 

The  toxaemia  should  be  treated  by  the  administration  of  two  to  three  copious 
(i  gallon-4  litres)  high  rectal  irrigations  of  normal  saline  solution  at  a  tempera- 
ture of  105-110°  F.  (40.5-43.5°  C),  daily;  moderate  diuresis  and  other  means 
calculated  to  assist  elimination  are  indicated.  While  any  symptoms  persist 
the  diet  should  be  entirely  of  milk. 

TETANY. 

Synonyms.    Intermittent  Tetanus;  Tetanilla. 

Definition.  A  nervous  affection  characterized  by  bilateral  intermittent 
or  continuous  tonic  spasms  of  the  extremities,  seldom  involving  one  limb 
only  and  rarely  becoming  general. 

.Etiology.  The  condition  affects  both  adults  and  children.  In  the  former 
it  occurs  in  a  so-called  epidemic  or  infectious  form  in  certain  parts  of  Europe 
among  young  workingmen,  especially  shoemakers  and  tailors;  as  a  result 
of  digestive  disorders  and  the  infectious  diseases;  as  a  complication  of  various 
nervous  diseases,  notably  exophthalmic  goitre,  syringomyelia  and  brain 
tumors;  following  morpnme,  ergot,  chloroform,  alcohol  and  lead  poisoning; 
in  ursemic  states;  in  pregnant  and  nursing  women;  and  as  a  result  of  removal 
of  the  thyroid  gland.  In  the  last  case  it  is  probably  due  to  the  excision  of 
the  parath3rroid  bodies  which  have  been  removed  with  the  gland. 

In  children  tetany  has  been  observed  in  digestive  disorders,  in  the  acute 
infectious  diseases  and  in  rickets. 
53 


834  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Pathology.  This  is  not  definitely  known.  It  is  supposed  that  the  para- 
thyroid glands  exercise  a  neutralizing  effect  upon  some  poisonous  substance 
produced  by  metabolism.  This  theory  would  account  for  tetany  following 
the  removal  of  these  bodies,  and  the  production  of  this  poison  in  such  an 
amount  that  the  parathyroids  are  unable  to  neutralize  it  may  account  for  the 
disease  in  other  cases. 

Symptoms.  The  spasm  of  tetany  is  usually  limited  to  the  limbs  and  ex- 
tremities. The  thumbs  are  flexed  into  the  palms;  the  fingers  are  adducted 
and  flexed  at  the  metacarpo-phalangeal  joints,  remaining  straight  at  the  pha- 
langeal articulations.  There  is  flexion  at  the  wrists  and  elbows  and  the  arms 
are  folded  over  the  chest.  In  the  lower  limbs  the  hips,  knees  and  ankles  are 
extended  and  the  toes  adducted  or  there  may  be  flexion  of  the  knees  and  dorsal 
flexion  of  the  feet.  The  skin  over  the  extremities  may  be  oedematous.  The 
muscles  of  the  face,  neck  and  body  are  seldom  affected;  rarely  there  may 
be  trismus  with  drawing  out  of  the  angles  of  the  mouth.  Tenderness  and 
pain  accompany  the  spasm  as  a  rule.  The  contractions  in  children  usually 
last  only  a  few  hours;  in  adults  they  may  be  prolonged  for  several  days  or 
even  weeks.  When  the  condition  is  very  acute  there  may  be  acceleration  of 
the  pulse  and  elevation  of  temperature. 

Other  symptoms  characteristic  of  the  disease  are  ChovosteWs — a  contraction 
of  the  muscles  caused  by  light  tapping  along  the  course  of  a  nerve;  Trousseau'' s 
— the  induction  of  spasm  by  pressure  over  the  affected  part,  especially  along 
a  nerve  trunk  or  over  a  blood-vessel;  Erh^s — exaggerated  electrical  irritability, 
especially  to  galvanism,  and  Hoffmann's — the  production  of  para?sthesia  by 
pressure  over  a  sensory  nerve.  Difficult  urination  or  inability  to  perform 
this  function  may  be  observed.     The  reflexes  are  exaggerated. 

The  prognosis  of  the  disease  is  good,  recovery  usually  taking  place  in  a 
few  days  or  more  rarely  after  a  month  or  two.  Recurrences  are  common 
especially  in  the  winter  and  early  spring. 

Death  may  occur  in  instances  due  to  severe  gastric  lesions  or  those  due  to 
removal  of  the  parathyroid  glands. 

Treatment  consists  first  in  removal  of  the  cause  of  the  condition;  any 
digestive  disorder  should  receive  appropriate  treatment  and  the  same  is  true 
of  rickets.  The  spasm  may  be  relieved  by  hot  baths,  an  ice  bag  applied  to 
the  spine  or  if  necessary  chloroform  may  be  given  by  inhalation;  frictions, 
massage,  passive  movements  and  the  electric  current  may  be  employed  with 
benefit  and  a  properly  hygienic  mode  of  life  should  be  prescribed. 

Of  drugs  those  which  have  a  sedative  action  in  spasmodic  conditions  should 
be  employed.  The  bromides,  hydrated  chloral  and  antipyrine  are  the  most 
useful.  In  cases  characterized  by  severe  pain  the  hypodermatic  adminis- 
tration of  morphine  may  be  necessary. 

The  extract  of  the  thyroid  gland  is  said  to  relieve  certain  patients,  even  those 


HYSTERIA.  835 

in  which  parathyroid  excision  has  not  been  performed.  The  beginning 
dosage  of  this  substance  is  5  grains  (0.33)  three  times  a  day. 

Thyroid  transplantation  has  been  suggested. 

In  instances  due  to  gastric  dilatation,  cure  may  result  from  one  of  the  surgical 
operations  adapted  to  the  treatment  of  this  condition,  or  if  this  mode  of  treat- 
ment is  contra-indicated  or  refused  by  the  patient,  frequent  and  thorough 
lavage,  according  to  the  methods  laid  down  under  the  treatment  of  gastric 
dilatation,  should  prove  beneficial. 

HYSTERIA. 

Definition.  An  abnormal  condition  of  the  nervous  system  characterized  by 
morbid  changes  in  the  functions  of  the  body  resulting  from  lack  of  mental 
control  over  acts  and  emotions  and  by  exaggeration  of  sensory  impressions. 

.etiology.  Heredity  has  a  direct  influence  upon  the  causation  of  this 
disease  and  even  if  true  hysteric  conditions  have  not  occurred  in  the  ancestry 
there  is  often  a  family  history  of  other  nervous  conditions,  such  as  epilepsy, 
insanity,  mental  degeneration,  etc.  Alcoholism  and  drug  habits  as  well  as 
consanguineous  marriage  are  factors  in  its  production.  While  hysteria  is 
more  common  among  females  it  is  by  no  means  seldom  observed  in  males. 
The  age  at  which  the  disease  is  most  frequently  met  is  from  that  of  puberty 
to  the  thirtieth  year.  The  Anglo-Saxon  races  are  much  less  prone  to  the 
disease  than  are  the  Latin  races  and  it  is  particularly  frequent  among  the 
Hebrews.  The  hysterical  temperament  is  likely  to  develop  in  pampered 
individuals  who  have  been  accustomed  to  excessive  sympathy  and  to  make 
much  of  every  slight  ailment. 

Hysteria  is  more  frequently  observed  in  the  poor  and  wealthy  than  among 
the  middle  classes.  It  is  predisposed  to  by  poor,  sordid  and  unhealthy  sur- 
roundings, by  lack  of  proper  noiirishment  and  life  under  severe  mental  strain 
or  worry. 

As  exciting  causes  may  be  mentioned  sudden  mental  or  traumatic  shock, 
fear,  joy,  grief,  business  reversal,  prolonged  illness,  sexual  excess  and  mastur- 
bation. 

Pathology.  Hysteria,  being  a  purely  functional  disease,  is  characterized 
by  no  recognizable  morbid  change  in  the  nervous  system. 

Symptoms.  These  occur  in  number  and  variety  equaled  by  no  other 
disease  and  comprise  the  symptoms  of  any  of  the  other  nervous  affections. 
In  the  earlier  stages  the  hysterical  patient  is  irritable,  emotional  or  despon- 
dent, magnifies  every  ill  and  is  anxious  for  sympathy;  he  may  give  himself 
over  to  mirth  or  may  indulge  in  attacks  of  weeping  without  apparent  reason. 
His  mentality  may  be  more  than  usually  active,  although  hysteria  may  occur 
in  the  mentally  deficient.     The  general  health  may  be  of  the  most  robust. 


836  DISEASES    or    THE    NERVOUS    SYSTEM. 

The  hysteric  convulsion  may  be  preceded  by  manifestations  such  as  those 
described  above  or  such  prodromata  as  vertigo,  neuralgic  pains,  localized 
cutaneous  anaesthesia  or  ovarian  tenderness  may  be  present.  At  times  an 
aura  resembling  that ^ of  the  true  epileptic  convulsion  may  be  observed;  most 
frequently  this  occurs  as  the  globus  hystericus,  which  is  characterized  by  a 
sensation  of  choking  as  if  there  were  obstruction  of  the  trachea  or  oesophagus. 

The  most  marked  type  of  the  convulsion  (hystero-epilepsy  or  hysteria  major) 
may  be  preceded  by  an  aura,  following  which  the  patient  may  utter  a  cry, 
falls  apparently  unconscious  and  exhibits  a  tonic  spasm;  this  is  followed  by 
the  clonic  stage  and  finally  by  relaxation  and  coma.  The  paroxysm  is  usually 
rather  longer  than  that  of  epilepsy.  The  second  stage  of  the  attack  is  termed 
"clownism"  by  Charcot  and  is  characterized  by  violent  and  exaggerated 
muscular  contortions,  emotional  display  or  cataleptic  poses.  In  the  third 
period  the  patient  assumes  various  attitudes  expressive  of  ecstasy,  happiness, 
terror  or  erotism.  The  fourth  period,  or  that  of  return  to  consciousness,  is 
characterized  by  delirious  and  hallucinatory  manifestations  in  which  the 
patient  seems  to  see  visions,  hear  voices  and  may  converse  with  imaginary 
persons.     These  hallucinations  may  persist  after  the  seizure  is  past. 

In  the  minor  form  of  convulsive  seizure  the  prodromata  may  be  similar  to 
those  described  above;  at  the  actual  onset  of  the  attack  the  patient  falls,  taking 
good  care  not  to  get  hurt;  the  spasms  consist  of  clonic  muscular  contractions 
which  may  involve  all  four  limbs  and  even  the  trunk.  The  contractions 
are  irregular  and,  although  the  patient  seems  unconscious,  he  gives  the  impres- 
sion to  the  experienced  observer  that  the  condition  is  feigned.  The  convul- 
sion passes  in  a  few  minutes  or  the  patient  may  be  aroused  by  the  use  of  a 
strong  galvanic  shock  or  by  dashing  a  small  amount  of  cold  water  in  the  face. 
The  seizure  does  not  leave  the  patient  in  a  somnolent  or  torpid  state  as  does 
that  of  epilepsy. 

During  the  non-convulsive  stage  the  hysterical  patient  may  exhibit  symp- 
toms referable  to  almost  any  organ  or  tissue  of  the  body;  these  may  be  divided 
as  follows: 

Motor  Symptoms.  In  addition  to  the  convulsive  movements  of  hysterical 
paroxysms  the  patient  may  simulate  various  forms  of  paralysis  such  as  hemi- 
mono-,  or  paraplegia,  tonic  muscular  spasms,  contractures  of  the  muscles 
of  the  extremities  or  of  the  neck,  disorders  of  coordination  or  tremors.  The 
paralysis  is  usually  hemiplegic  and  more  often  on  the  left  side,  the  face  being 
seldom  affected.  Limbs  apparently  useless  for  locomotion  may  be  moved 
while  the  patient  lies  in  bed  and  if  one  leg  is  apparently  paralyzed  it  is  drag- 
ged shufflingly  along  while  the  other  limb  is  taking  ordinary  steps,  and  is  not 
swung  outward  as  in  true  hemiplegia.  Ataxia  may  accompany  the  paralysis 
which  may  be  either  spastic  or  flaccid.  Vocal  cord  paralysis  with  loss  of 
voice  is  not  rare  and  may  be  demonstrated  by  laryngoscopic  examination 


HYSTERIA.  837 

which  is  particularly  easy  in  hysterical  patients,  because  of  the  anaesthesia 
of  the  pharynx,  one  of  the  stigmata  of  hysteric  conditions. 

The  reflexes  may  be  exaggerated,  and  the  so-called  hysterical  joint  may  be 
observed.  The  latter  is  characterized  by  pain  and  swelling,  of  sudden  onset, 
usually  affecting  the  knee  or  hip.  Motion  is  interfered  with  and  in  conse- 
quence muscular  atropny  from  disuse  may  ensue. 

Contracture  of  the  abdominal  muscles  may  result  in  the  so-called  "  phantom 
tumor."  This  is  most  frequently  seen  in  the  umbilical  region  and  at  times 
very  accurately  simulates  a  firm  and  solid  growth.  It  is  considered  to  be  due 
to  a  spasmodic  contraction  of  the  diaphragm,  the  recti  abdominis  being  at 
the  same  time  relaxed,  the  vertebral  column  curved  forward  and  the  intestines 
distended.  Pseudocyesis  or  false  pregnancy  is  a  variety  of  this  condition. 
Such  spurious  tumors  disappear  if  the  patient  is  subjected  to  general  anaes- 
thesia. 

Sensory  Symptoms.  Of  these  the  most  common  are  areas  of  cutaneous 
hyperaesthesia,  anaesthesia  or  paraesthesia,  the  latter  consisting  of  sensations 
of  numbness  or  tingling,  formication  or  of  heat  and  cold.  Symptoms  refer- 
able to  the  organs  of  special  sense  may  occur,  such  as  mere  lessened  acuity 
of  sight  or  diminution  of  the  visual  field.  Other  disorders  are  total  blindness 
(never,  however,  hemianopsia)  and  loss  of  color  sense.  Deafness  is  not  uncom- 
mon and  loss  of  the  senses  of  smell  and  taste  is  by  no  means  rare. 

Vaso-motor  Symptoms.  Paleness  or  blushing  of  the  skin,  as  well  as  localized 
areas  of  coldness  or  heat,  may  be  present.  (Edema  has  been  observed.  Haemop- 
tyses  and  haemateraesis  may  be  alleged  by  the  patient  but  in  these  patients  the 
blood  as  a  rule  comes  from  the  gums  and  then  only  in  small  amount.  ■  Hjster- 
ical  haemorrhages  into  the  skin  have  been  reported  but  must  be  most  unusual. 

Such  secretory  disorders  as  excessive  or  diminished  perspiration,  diminu- 
tion or  increase  of  the  saliva  and  lessened  or  increased  urinary  excretion  are 
frequently  met,  polyuria  especially  so,  the  urine  being  profuse  in  quantity, 
light  in  color  and  of  low  specific  gravity.  The  urine  in  marked  instances  often 
undergoes  further  change,  the  urates  and  phosphates  being  diminished  and 
the  normal  ratio  (1  to  3)  of  the  earthy  to  the  alkaline  phosphates  being  changed 
to  I  to  2  even  i  to  i ;  at  the  same  time  the  urine  is  diminished  in  quantity. 
This  change  is  considered  by  the  disciples  of  Charcot  to  be  a  differential 
diagnostic  point  between  convulsive  hysteria  and  true  epilepsy. 

Digestive  Symptoms.  These  are  common  and  may  consist  of  simple  indi- 
gestion,  gastralgia,  perversions  of  appetite  or  flatiilence. 

Vomiting  is  frequent  and  may  be  voluntarily  induced  and  oesophageal 
spasm  resulting  in  dysphagia  may  occur.  Constipation  is  frequent  while 
diarrhoea  is  seldom  seen. 

Respiratory  symptoms  consist  of  the  hysterical  cough  which  occurs  parox- 
ysmally,  is  harsh  and  is  accompanied  by  little  or  no  expectoration;  of  dyspnoea 


838  DISEASES    OF    THE    NERVOUS    SYSTEM. 

which  may  disappear  upon  diversion  of  the  patient's  attention,  and  obstinate 
hiccough. 

Cardiac  symptoms,  such  as  arrhythmia,  tachycardia  or  bradycardia  and 
attacks  of  syncope,  are  not  unusual. 

Mental  symptoms  are  prominent  and  variable.  The  patient  is  emotional, 
easily  worried  and  excitable;  the  temper  is  irritable  and  hallucinations  are 
frequent.  True  insanity  may  develop  and  rarely  cataleptic  trances  have 
been  observed. 

Hysterical  fever  has  been  reported  as  reaching  a  temperature  of  105  to 
110°  F.  (40.5-43.5°  C.)  or  even  higher.  Such  a  rise  of  temperature  occurs 
irregularly  and  usually  patients  exhibiting  this  symptom  are  malingerers 
and  in  some  way  manipulate  the  thermometer;  close  watching  usually  results 
in  their  detection. 

The  prognosis  in  hysteria  as  regards  life  is  good,  fatal  instances  being  rarely 
if  ever  seen.  As  regards  recovery  the  prognosis  depends  upon  the  type  of  the 
disease  in  hand.  Mild  instances  may  recover  within  a  few  weeks,  while  others 
may  go  on  for  a  numoer  of  years  exhibiting  intermissions  and  variations  of 
the  symptoms. 

Treatment.  Prophylaxis  of  the  disease  consists  in  combating  all  the 
influences  mentioned  in  the  section  on  aetiology  asMikely  to  be  predisposing 
factors.  Children,  especially  those  of  neurotic  tendency  or  heredity,  should 
be  most  carefully  trained,  they  should  be  kept  from  association  with  hysterical 
persons  and  should  be  subjected  to  a  proper  system  of  training  and  education, 
self-control  and  denial  being  insisted  upon,  while  over-indulgence  and  the 
gratification  of  every  whim  should  be  discouraged. 

In  the  treatment  of  hysteria  much  depends  upon  the  personality  of  the 
physician.  He  should  be  of  firm  character,  insistent  upon  the  proper  fulfil- 
ment of  his  orders  and  at  the  same  time  sympathetic  within  proper  limits. 
The  milder  hysterical  manifestations  seldom  require  much  treatment  other 
than  that  directed  at  the  cause  of  the  condition;  this,  in  the  mild  type  as  well 
as  in  the  more  marked  form  of  the  disease,  should  be  removed  if  possible. 
The  patient's  general  physical  condition  should  be  carefully  supervised  and 
any  abnormality  corrected;  at  the  same  a  regular  and  hygienic  mode  of  life 
should  be  insisted  upon,  with  proper  diet,  sufficient  exercise  and  fresh 
air,  and  particularly  should  the  patient  be  provided  with  some  congenial 
occupation  in  which  he  is  able  and  willing  to  engage.  Tonics,  especially 
arsenic  and  iron  in  moderate  doses,  are  usually  indicated.  For  the  hyper- 
irritability  of  the  nervous  system  various  sedatives  may  be  prescribed  such  as 
the  bromides,  including  monobromated  camphor,  asafoetida,  castoreum, 
musk,  chloroform,  acetphenetidine,  exalgine  and  the  preparations  of  valerian. 
Hydrated  chloral  and  morphine,  if  used  at  all,  should  be  employed  with  the 
utmost  caution. 


HYSTERIA,  839 

The  pains  should  be  treated  by  means  of  the  thermo-cautery  and  the  gal- 
vanic current.  Paralyses  and  contractures  necessitate  the  employment  of 
massage,  manipulation  and  forced  movements  in  connection  with  the  electric 
current.  Laryngeal  paralyses  may  respond  to  electric  treatment  and  anaes- 
thesia to  frequent  applications  of  the  f aradic  current.  Paralyses  and  contrac- 
tures of  the  limbs  may  persist  despite  anything  that  can  be  done.  Hysterical 
vomiting  may  necessitate  the  employment  of  Debove's  method  of  forced 
feeding  (see  p.  629). 

The  hysterical  attack  may  be  treated  by  sprinkling  cold  water  in  the  pa- 
tient's face  or  by  flicking  the  face  with  a  wet  napkin,  the  flesh  may  be  pinched 
vigorously,  or  it  may  be  well,  having  seen  that  the  patient  is  properly  disposed 
of,  to  leave  her,  allowing  her  to  emerge  from  the  seizure  and  find  herself  alone, 
no  one  being  present  to  offer  sympathy.  It  has  been  suggested  that  pressure 
upon  the  epigastric  region  or  over  the  ovaries  will  cause  a  cessation  of  the 
spasmodic  manifestations.  In  spite  of  any  rigidity  of  the  abdominal  parietes 
the  pressure,  if  continuous  and  energetic,  will  often  prove  effectual.  In  the 
male  pressure  may  be  made  over  the  same  areas.  A  galvanic  current  of  from 
five  to  ten  milliamperes,  one  pole  at  the  front  of  the  body  and  the  opposite 
behind,  may  be  employed.  Repeated  sudden  interruptions  of  the  current 
increase  its  efficacy.  Another  method  of  treatment,  which  has  the  advantage 
of  entire  safety,  consists  in  giving  inhalations  of  amyl  nitrite.  This  drug 
rarely  fails  to  stop  the  seizure  and  has  an  excellent  mental  effect  upon  the 
patient,  ^ther  and  ethyl  bromide  may  also  be  administered  by  inhalation 
but  chloroform  is  hardly  disagreeable  enough  to  be  of  use.  Capsules  of  aether 
which  explode  in  the  stomach  are  sometimes  effective. 

In  marked  types  of  hysteria  no  treatment  excels  that  first  advocated  by 
Weir  Mitchell.  It  is  particularly  indicated  in  those  patients  who  are  confined 
to  bed.  It  consists  in  placing  the  patient  entirely  under  the  care  of  a  compe- 
tent nurse  and  if  possible  removing  her  from  association  with  her  family  and 
sympathizing  friends,  and,  while  the  treatment  should  be  varied  to  meet  the 
exigencies  of  each  patient,  its  main  details  are  as  follows:  The  patient  is  kept 
absolutely  quiet  in  bed,  is  not  allowed  to  read  or,  at  first,  even  to  feed  herself. 
Massage  and  electricity  are  employed  for  gradually  lengthening  periods,  being 
omitted,  however,  during  the  menstrual  epoch.  A  slowly  interrupted  far- 
adic  current  is  to  be  preferred  to  the  galvanic.  At  first  the  diet  is  entirely  of 
milk  either  skimmed  or  diluted  with  lime,  barley  or  carbonated  water  in  pro- 
portion of  about  4  or  5  to  i;  4  to  6  ounces  (120.0  to  180.0)  are  given  every 
two  hours,  this  quantity  being  gradually  increased  in  accordance  with  the 
tolerance  of  the  patient.  If  necessary  the  milk  may  be  peptonized.  After 
from  seven  to  ten  days,  the  milk  being  continued,  solid  food  is  allowed  at  mid- 
day. A  chop  or  raw  oysters  with  bread  and  butter  or  toast  and  a  cup  of  cocoa 
or  coffee  make  an  acceptable  luncheon  and  after  some  days  a  breakfast  con- 


840  DISEASES    OF    THE    NERVOUS    SYSTEM. 

sisting  of  an  egg  and  a  roll  or  a  few  biscuit  is  added.  The  patient  should 
be  given  a  sponge  bath  daily.  In  from  four  to  six  weeks  the  patient  is  allowed 
to  sit  up,  a  few  moments  at  first,  but  as  time  passes,  for  longer  periods  and  still 
later  she  is  allowed  to  drive  out  and  to  take  short  walks.  The  latter  are 
lengthened  little  by  little  until  the  patient  is  able  to  take  considerable  amounts 
of  exercise  without  fatigue.  The  treatment  should  be  carried  out  with  the 
utmost  regard  for  system  and  regularity,  a  schedule  being  made  for  the  day, 
the  hours  for  feeding,  massage,  electricity,  exercise,  rest,  etc.,  being  fixed. 
It  is  important  that  the  patient  should  be  allowed  to  rest  for  an  hour  after 
massage  and  the  latter  and  electricity  should  never  be  given  in  close  conjunc- 
tion; an  interval  of  two  to  four  hours  is  not  too  great. 

Most  excellent  results  have  followed  this  method  of  treatment  particularly 
in  thin,  poorly  nourished  individuals. 

Hydrotherapeutic  measiires  are  often  of  service  in  hysterical  conditions, 
the  nervous  irritability  responding  particularly  well  to  hot  and  cold  packs. 
Hypnotism  has  been  employed  in  the  treatment  of  hysteria,  especially  in 
France,  but  while  remarkable  results  have  in  numerous  instances  been  achieved, 
most  American  writers  unite  in  asserting  that  it  should  be  used  with  the 
utmost  caution  if  at  all. 

NEURASTHENIA. 

Synonyms.  Nervous  Exhaustion;  Nervous  Prostration;  The  American 
Disease. 

Definition.  Neurasthenia  is  a  functional  disorder  of  the  nervous  system 
characterized  by  exhaustion  of  both  the  mental  and  physical  energies  of  the 
patient. 

.Etiology.  The  influence  of  heredity  in  this  disease  is  well  recognized, 
neurasthenia  often  occurring  in  those  whose  parents  have  been  of  neurotic 
or  hysterical  type  or  have  lived  the  rapid,  worrisome  life  that  has  become 
too  common  during  the  past  three  decades.  Neurasthenia  is  more  common 
in  men  than  in  women  and  results  from  over-work,  attended  with  excessive 
mental  strain  or  worry,  as  well  as  from  the  abuse  of  alcohol  and  tobacco,  and 
the  use  of  morphine.  It  occurs  secondary  to  syphilis  and  the  acute  infec- 
tious diseases,  particularly  influenza;  it  may  be  caused  by  sexual  excesses 
and  perversions  and  by  traumatism. 

Pathology.  No  definite  morbid  change  in  the  nervous  system  has  been 
recognized  as  characteristic  of  neurasthenia. 

Symptoms.  These,  in  many  instances,  are  similar  to  those  of  hysteria  of  the 
mild  type  but  are  varied,  depending  upon  the  organ  or  organs  chiefly  affected 
by  the  state  of  nerve  weakness.  In  the  cardiac  form  there  are  rapid  and 
irregular  heart  action  perceptible  to  the  patient,  and  pain  referred  to  the  pre- 


NEURASTHENIA.  84I 

cordium.  In  the  gastric  type  there  are  epigastric  pulsations  and  sensations 
of  distress  after  eating,  with  borborygmi.  Vaso-motor  manifestations,  such  as 
sudden  hot  flushes  or  sweats,  may  occur  and  the  patient  may  suffer  from 
vertigo  or  attacks  of  syncope.  In  another  type  of  the  disease  the  symptoms 
are  referable  chiefly  to  the  nervous  system  and  consist  of  muscular  weakness, 
often  so  marked  as  to  interfere  with  locomotion  and  the  performance  of  ordi- 
nary acts  with  the  hands  and  fingers,  hypersesthesiae  and  paraesthesiae  and 
disorders  of  the  special  senses.  The  mentality  may  be  affected  and  the 
patient  suffers  from  low  spirits,  despondency  or  irritability  of  temper.  Insom- 
nia and  mental  confusion  are  not  rare  and  the  suicidal  tendency  may  occur. 

Sexual  neurasthenia  is  not  uncommon,  the  patient  complaining  of  frequent 
nocturnal  emissions,  a  dread  of  impotence,  which  may  result  in  inability  to 
perform  the  sexual  act,  and  spermatorrhoea,  the  discharge  of  seminal  fluid 
often  accompanying  micturition  or  defsecation.  In  males  suffering  from  this 
type  of  the  disease  there  are  frequently  pain  and  tenderness  of  the  testicles; 
ovarian  tenderness  and  menstrual  disorders  are  frequently  associated  with 
neurasthenia  in  women. 

Polyuria  is  frequently  present,  the  urine  being  of  light  color  and  low  specific 
gravity  although  patients  in  whom  the  urine  is  diminished  in  quantity  and  dark 
in  color  may  be  met.  Purinsemic  conditions  are  not  infrequent  complica- 
tions of  neurasthenia  and  this  fact  should  not  be  forgotten  when  treatment 
is  taken  under  consideration. 

The  prognosis  is  good  in  patients  who  are  willing  and  financially  able  to 
undergo  the  treatment  necessary. 

Treatment.  Prophylaxis  consists  in  the  attempt  to  so  train  children  of 
neurotic  inheritance  and  tendency  that  both  the  mental  and  physical  forces 
may  be  conserved  and  rendered  as  resistant  as  possible.  Over-indulgence  is 
to  be  avoided  and  the  child's  food,  school  work,  exercise  and  hours  of  sleep 
should  be  studiously  regulated.  Highly-strung  and  irritable  children  should 
be  managed  with  great  tact,  the  nurse  or  teacher  should  never  lose  her  own 
temper  while  controlling  the  child  and  any  excessive  excitement  or  emotion 
is  best  managed  by  giving  a  warm  bath  followed  by  a  sponge  off  with  cool 
water.  After  this  the  child  may  be  put  to  bed  for  a  few  hours  and  will  usually 
go  to  sleep. 

Prophylaxis  in  adults  consists  in  the  avoidance  of  excessive  business  worry 
and  the  leading  of  a  regular  life,  particular  attention  being  paid  to  exercise 
and  sleep;  frequent  vacations  may  be  advisable  and  it  is  often  well,  if  the 
patient  can  arrange  it,  for  him  to  take  these  under  conditions  totally  different 
from  those  to  which  he  is  accustomed  at  home  and  away  from  sympathizing 
friends  and  relatives.  The  diet  of  the  neurasthenic  should  be  simple  and 
nourishing  and,  if  allowed  at  all,  tea,  coffee,  tobacco  and  alcohol  should  be 
used  in  moderation. 


842  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Just  as  in  the  treatment  of  hysteria  tiie  physician  about  to  take  in  hand  a 
case  of  neurasthenia  should  seek  to  gain  the  imphcit  confidence  of  liis  patient. 
Naturally  the  ability  to  accomplish  this  object  depends  to  a  great  extent  upon 
the  personality  of  the  physician.  The  latter's  visits,  while  regular,  should  not 
be  too  frequent  and  should  be  made  at  definite  intervals.  Much  discretion 
should  be  used  in  responding  to  unnecessary  calls  from  the  patient.  It  is, 
perhaps,  better  to  have  an  understanding  with  the  nurse  in  this  regard  and 
to  suggest  that  she  use  her  discretion  in  transmitting  such  calls.  The  selection 
of  a  nurse  is  an  important  item.  She  should  be  a  vigorous  and  robust  woman 
and  of  a  temperament  as  little  nervous  and  emotional  as  possible. 

The  rest  cure  described  in  the  section  on  the  treatment  of  hysteria  was  first 
devised  for  neurasthenic  patients  and  in  many  instances,  especially  obstinate 
and  resistant  ones  in  women  or  those  complicated  by  drug  habit,  achieves 
excellent  results. 

Hydrotherapy  is  an  efl&cacious  form  of  treatment  and,  if  about  to  employ 
it,  the  patient  should  be  studied  in  order  to  ascertain  whether  his  state  is  one 
of  nervous  excitation  or  of  depression.  In  the  former  case  the  patient  may 
not  possess  sufiicient  resistance  to  undergo  a  rigid  course  of  bath  treatment 
but  will  need  to  be  strengthened  by  means  of  a  systematic  rest  and  diet  cure 
before  the  hydrotherapeutic  measures  are  admissible.  In  the  ordinary  type 
of  neurasthenia  the  preferable  mode  of  hydrotherapeutic  procedure  is  the 
cold  douche  given  but  a  short  time  and  under  considerable  pressure.  The 
jet  should  be  applied  in  turn  to  all  parts  of  the  body  except  the  head.  Very 
excitable  and  emotional  patients  are  benefited  by  the  cold  wet  pack  or  half 
bath,  followed  by  vigorous  friction  and  exercise  in  order  to  produce  a  satis- 
factory reaction.  If  the  cold  douches  impress  the  patient  unfavorably  the 
Scotch  douche  may  be  substituted.  The  douches  are  usually  given  twice  a 
day,  the  patient  being  allowed  to  lie  down  for  an  hour  or  two  after  each. 

Electric  treatment  is  often  useful  in  connection  with  hydrotherapeutic 
procedures.  Galvanism  or  Franklinization  associated  with  the  high  frequency 
current  and  general  faradization  may  be  employed.  The  Franklinic  and 
faradic  currents  and  the  actual  cautery  may  be  employed  in  localized  pain. 

Patients  able  to  travel  are  often  greatly  benefited  by  a  sea  voyage  or  a 
sojourn  at  one  of  the  various  spas  where  baths  may  be  taken  and  mineral 
waters  drunk.  The  latter  frequently  have  an  excellent  mental  effect  upon 
the  patient  and  the  regular  mode  of  life  insisted  upon  at  such  resorts  is  bene- 
ficial. 

With  regard  to  medicinal  treatment  is  may  be  said  that  while,  as  a  rule, 
drugs  should  be  avoided  if  possible,  there  are  cases  in  which  good  results 
may  result  from  their  use.  Tonics,  especially  if  anaemia  is  present,  are 
often  indicated  and  of  these  those  worthy  of  special  mention  are  iron,  strych- 
nine and  the  arsenic  preparations.     Sodium  cacodylate  or  iron  cacodylate 


NEURASTHENIA.  843 

may  be  given  hypodermatically  if  the  stomach  is  intolerant,  the  former  in 
doses  of  I  of  a  grain  (0.05)  twice  a  day,  the  latter  in  doses  of  y\  of  a  grain 
(0.02).  The  glycerophosphates  may  often  be  employed  with  benefit  as  follows: 
1^  calcii  glycerophosphalis,  gr.  ivss  (0.30);  sodii  glycerophosphatis,  potassii 
glycerophosphatis,  magnesii  glycerophosphatis,  aa,  gr.  iss  (o.io);  ferri  glycero- 
phosphatis, gr.  I  (0.05).  Fiat  chartula  no.  i.  Sig.  Take  two  such  powders 
daily;  or  I^  calcii  glycerophosphatis, 5 iss  (6.0);  sodii  glycerophosphatis,  potassii 
glycerophosphatis,  magnesii  glycerophosphatis,  ferri  glycerophosphatis,  aa 
gr.  XXX  (2.0),  tincturae  kolas,  Siiss  (lo.o);  sjTupi  aurantii  corticis  amari,  q.s. 
ad  §vi  (2000).  Misce  et  signa  one  tablespoonful  during  breakfast  and 
dinner. 

The  syrup  of  hypophosphites  may  also  be  prescribed  or  subcutaneous 
injections  of  sodium  phosphate  two  parts,  alcohol  five  parts,  and  distilled  water 
100  parts,  may  be  given.  Of  the  latter  15  to  45  minims  (1.0-3.0)  should  be 
•injected  daily. 

Another  drug  which  has  recently  been  much  advocated  is  lecithin.  It  is 
given  in  pill  form — 4^  to  yj  grains  (0.3-0.5)  daily — or  hypodermatically  in 
oily  solution,  each  injection  containing  f  to  2J  grains  (0.05-0.15)  of  lecithin. 

Injections  of  artificial  sera  have  been  recommended  as  a  stimulant  to  the 
nervous  system  and  to  lower  blood  pressure.  Such  sera  may  be  composed 
of  phenol  in  crystal  form  i  part,  sodium  chloride  2  parts,  sodium  phosphate 
4  parts,  sodium  sulphate  8  parts,  distilled  water  100  parts,  or  sodium  phosphate 
10  parts,  sodium  sulphate  5  parts,  sodium  chloride  2  parts,  crystalline  phenol 
J  part,  distilled  water  100  parts.  Of  the  former  solution  2J  drachms  (lo.o) 
may  be  injected  daily;  of  the  latter  i J  to  2^  drachms  (5.0-10.0)  twice  a  week. 
The  solutions  should  be  sterilized  immediately  before  administration. 

The  treatment  of  cardiac  symptoms:  The  application  of  cold  wet  compres- 
ses to  the  precordium  or  of  the  aether  spray  will  relieve  the  palpitation  or  if 
this  is  a  result  of  gastric  disorder,  treatment  should  be  directed  to  the  stomach. 
The  bromides  and  the  valerates  may  be  indicated  when  this  symptom  is 
the  result  of  nervous  excitability.  The  systematic  employment  of  hydro- 
therapeutic  measures  will  tend  to  diminish  the  cardiac  irritability. 

Gastric  symptoms  should  be  treated  according  to  the  principles  suggested 
in  the  sections  on  the  treatment  of  neuroses  of  the  stomach. 

The  pains  and  excessive  nervousness  may  be  allayed  by  the  bromides  or 
occasional  doses  of  salipyrine,  acetphenetidine  or  exalgine.  For  the  sleepless- 
ness a  warm  bath  or  a  wet  pack  taken  before  retiring  will  often  prove  effectual. 
If  drugs  are  necessary  such  mild  hypnotics  as  sulphonethylmethane  (gr.  x — 
0.66),  sulphonmethane  (gr.  xx — 1.33)  or  veronal  (gr.  x  to  xv — 0.66  to  i.o)  may 
be  prescribed  at  intervals.     Morphine  should  never  be  allowed. 

In  sexual  neurasthenia  with  nocturnal  emissions  and  spermatorrhoea  general 
treatment  with  attention  to  exercise  and  mode  of  life,  together  with  the  admin- 


844  DISEASES    OF    THE    NERVOUS    SYSTEM. 

istration  of  hyoscyamus  and  the  bromides,  is  to  be  advised.  The  loins  should 
be  sponged  off  with  cold  water  or  a  cool  sitz  bath  taken  before  retiring;  no 
food  should  be  eaten  just  before  going  to  bed  and  the  rectum  should  be  kept 
empty  to  avoid  pressure  upon  the  prostate  and  seminal  vesicles.  The  pa- 
tient's mind  should  be  kept  occupied  and  off  from  thoughts  upon  sexual  mat- 
ters and  he  should  be  assured  that  he  has  greatly  magnified  his  trouble  and 
the  possible  consequences  thereof. 

The  recent  work  done  upon  eye-strain  renders  it  of  paramount  importance 
that  any  defect  of  vision  should  be  properly  corrected  by  the  ophthalmologist. 

THE  NEURASTHENIA  OF  THE  MENOPAUSE. 

The  incidence  of  the  menopause  (climacteric  or  change  of  life)  is  character- 
ized in  many  instances  by  the  appearance  of  numerous  manifestations  analo- 
gous to  those  of  ordinary  neurasthenia.  The  anatomical  basis  of  these  is 
undoubtedly  a  disturbance  of  the  sympathetic  nervous  system.  On  no 
other  ground  can  the  symptoms  be  satisfactorily  accounted  for  and  on  no 
other  theory  can  the  triad  of  pallor,  flush  and  sweating,  in  whatever  sequence 
they  may  appear,  the  tachycardia,  the  dyspnoeas,  the  neuralgias,  the  vertigo, 
faintness,  tinnitus  aurium,  headache,  pruritus,  the  serous  diarrhoeas,  the 
veritable  downpour  of  urine  and  the  varying  mental  moods  be  explained. 
At  the  menopause,  the  slowly  increasing  blood  pressure  of  the  inter-menstrual 
period  which  reaches  its  maximum  at  the  onset  of  the  flow,  falls  rapidly  to 
its  minimum  at  the  termination  of  the  period,  going  on  in  rhythmical  cycle 
for  about  thirty  years,  is  now  disturbed;  vaso-dilatation  and  vaso-constriction 
succeed  and  precede  one  another  in  irregular  waves.  Pathologically  there 
is  an  actual  insanity  of  vaso-motor  function. 

The  majority  of  the  patients  who  suffer  from  symptoms  due  to  the  meno- 
pause consult  the  specialist  in  internal  medicine  or  the  family  physician.  It 
is  equally  true  that  both  these  fully  realize  the  importance  of  gynaecological 
operations  and  treatment  and  insist  that  their  patients  shall  receive  them 
should  such  be  necessary;  consequently  it  behooves  the  physician  to  be  able 
to  make  a  proper  diagnosis  of  the  condition.  In  accomplishing  this  object 
malaria,  purinaemia  and  other  general  maladies,  as  well  as  diseases  of  the 
circulatory,  alimentary  and  nervous  systems,  must  be  intelligently  sought  and 
excluded.  Next,  all  local  pathological  conditions  as  determined  by  the  gyne- 
cologist must  be  remedied.  Having  concluded  that  the  symptoms  are  due 
to  the  menopause,  we  have  immediate  necessity  for  a  working  hypothesis 
which  shall  at  once  explain  the  manifestations  of  the  condition  and  serve  as 
a  basis  for  a  successful  treatment.  Such  a  one  has  been  discussed  above  and 
as  has  been  previously  stated,  the  patient's  state  can  best  be  accounted  for  by 
holding  the  sympathetic  nervous  system  responsible. 


THE   NEURASTHENIA   OF    THE    MENOPAUSE.  845 

Treatment.  Disturbed  balance  of  the  sympathetic  nervous  system  is  most 
rapidly  benefited  by  the  use  of  the  bromides.  If  the  pulse  is  of  good  volume, 
tension  and  rate,  sodium  bromide  in  15  grain  (i.o)  doses  four  times  daily 
should  be  prescribed.  If  left  ventricular  hypertrophy  exists  the  potassium  salt 
in  the  same  dosage  should  be  given.  If  cardiac  dilatation  has  supervened  or 
arterial  tension  is  lowered,  the  ammonium  salt,  the  dose  also  being  of  the 
same  size,  is  preferred.  In  the  presence  of  dyspeptic  symptoms  or  if  prolonged 
administration  seems  likely  to  be  necessary,  strontium  bromide  is  advisable. 
What  the  bromides  accomplish  with  rapidity  arsenic  will  achieve  more  slowly 
but  with  greater  permanence,  consequently  as  the  condition  responds  to  the 
former,  the  doses  are  diminished  and  arsenic  is  added,  the  solution  of  potas- 
sium arsenite  (Fowler's  solution)  in  3  minim  doses  (0.2)  after  meals,  being  the 
most  useful  preparation.  The  dosage  should  be  gradually  increased  until 
slight  untoward  symptoms  arise,  when  the  initial  dose  is  resumed. 

Since  most  of  the  patients  are  anaemic,  iron,  as  iron  and  ammonium  citrate, 
in  dose  of  4  grains  (0.25)  three  times  daily  is  advisable.  The  following 
combination  of  these  remedies  is  suggested:  Strontium  bromide  i  ounce 
(30.0);  solution  of  potassium  arsenite  2  drachms  (8.0);  iron  and  ammo- 
nium citrate  2^  drachms  (lo.o);  cinnamon  water  to  4  ounces  (120.0).  Of  this 
mixture  i  teaspoonful  (4.0)  in  a  wineglass  (60.0)  of  water  is  taken  after  each 
meal  and  at  bed  time.  As  the  patient  progresses  toward  recovery  the 
amount  of  bromide  is  to  be  diminished  while  that  of  the  arsenic  is  increased. 

In  some  instances  when  cessation  of  the  menstruation  is  speedily  established, 
and  particularly  after  surgical  removal  of  the  ovaries  in  young  subjects,  the 
administration  of  ovarian  extract,  5  grains  (0.33)  thrice  daily  for  one  or  two 
months  is  necessary;  the  dose  should  be  gradually  lessened.  In  other  instances 
the  vaso-motor  disturbance  may  be  more  readily  controlled  by  smaller — 3 
grain  (0.2) — doses  in  connection  with  the  bromides  and  arsenic.  Such  em- 
ployment of  ovarian  extract  is  only  exceptionally  advisable. 

For  special  indications  further  medication  may  be  prescribed:  (i)  Menor- 
rhagia: This  may  be  controlled  by  absolute  quiet  in  bed  with  ice  bags  over 
the  hypogastrium.  The  fiuidextract  of  hydrastis  30  drops  (2.0)  twice 
daily,  or  better,  cotarnine  hydrochloride,  either  by  the  mouth  in  5  grain 
(0.33)  doses  in  capsule,  or  hypodermatically  in  the  same  dose  in  a  10  percent, 
aqueous  solution,  is  useful.  A  formula  which  is  often  effective  consists  of 
fiuidextract  of  hydrastis  2  ounces  (60.0);  ergotine  2 J  drachms  (lo.o);  syrup 
to  5  ounces  (150.0).  Of  this  the  dose  is  a  teaspoonful  (4.0)  in  a  wineglass 
of  water  every  hour  or  two.  In  rare  cases  tamponade  of  the  uterus  under 
thorough  aseptic  precautions  may  be  necessary;  more  seldom  it  may  be  ad- 
visable to  add  10  percent,  of  gelatin  to  the  gauze,  the  latter  being  plain  or 
impregnated  with  iodoform. 

2.  Neuralgia.     This   is  best  relieved  by  pills  of  monobromated  camphor, 


846  DISEASES    OF    THE    NERVOUS    SYSTEM. 

2  grains  (0.13);  quinine  valerate  i  grain  (0.065);  extract  of  gelsemium 
(B.  P.)  2  grains  (0.13);  extract  of  belladonna  leaves  3-  of  a  grain  (0.012) 
given  four  or  five  times  daily.  As  an  alternative  pills  of  extract  of  belladonna 
leaves  -g-  of  a  grain  (0.012);  extract  of  gelsemium  (B.P.)  2  grains  (0.13) 
and  zinc  valerate  3  grains  (0.2)   may  be  administered  twice  daily. 

3.  Psychic  Disturbance.  Sulphonethylmethane  (trional)  15  grains  (i.o) 
combined  with  heroine,  yV  of  a  grain  (0.005)  given  at  bedtime  will 
tend  to  insure  sleep  during  the  night  and  quiet  during  the  following  day; 
or  a  suppository  of  dionine,  \  grain  (0.03),  in  cocoa  butter  may  accomplish 
the  same  result.     These  prescriptions  should  be  used  only  occasionally. 

4.  Palpitation.  The  tincture  of  veratrum  in  15  minim  (i.o)  doses 
thrice  daily  to  which  may  be  added  tincture  of  gelsemium  8  minims  (0.5), 
is  usually  eflfectual. 

5.  Constipation  is  best  remedied  by  the  use  of  saline  laxatives  as  Rochelle 
salt  or  such  waters  as  Hunyadi  Janos,  Apenta,  Rubinat  Condal  and  the  like. 
The  other  symptoms  referable  to  the  digestive  tract  are  also  benefited  by  the 
judicious  use  of  salines. 

6.  Diarrhoea  is  usually  of  the  nervous  type  and  will  yield  readily  to  the 
bromides. 

In  the  daily  life  of  the  patient,  fatigue,  wakefulness,  sexual  excitation,  cold 
baths  and  especially  sea  bathing,  spiced  and  highly  seasoned  food,  tea,  coffee 
and  alcohol  in  all  forms  are  to  be  avoided.  In  other  words  a  quiet  life  from 
which  all  extraneous  sources  of  irritation  are  removed  is  advisable.  When 
it  is  remembered  that  at  the  menopause  the  mind  of  the  patient  is  in  a  state 
of  unstable  equilibrium  the  importance  of  this  last  injunction  is  apparent. 
Rest,  therefore,  both  physical  and  mental,  is  doubly  essential.  For  exercise 
and  to  secure  the  necessary  fresh  air,  daily  walks  in  the  open,  but  not  to  the 
point  of  fatigue,  are  suggested. 

AMOK  OR  AMUCK. 

This  is  a  maniacal  condition,  seen  amongst  the  Malay  race,  in  which  the 
individual  affected  runs  through  the  streets  in  frenzy  and  with  sword  or  other 
lethal  weapon  in  hand  slays  or  maims  every  one  he  meets  until  he  meets  death 
at  his  own  hand  or  that  of  another.  The  disease  as  a  rule  attacks  males  and 
occurs  in  young  adult  life.  .  According  to  the  most  recent  studies  the  condition 
of  Amok  includes  several  states  in  which  the  affected  individual  commits 
violent,  unthinking,  unpremeditated  and  impulsive  acts  while  mentality  is 
blurred.  Certain  instances  are  classed  as  the  insanity  of  adolescence,  others  as 
epilepsy,  others  under  the  rather  indefinite  term  malarial  psychosis,  while  still 
others  are  inexplicable. 

Before  the  onset  of  the  attack  proper  the  patient  for  a  number  of  days  is 


TRAUMATIC    NEUROSES.  847 

lethargic,  stuporous  or  morose  and  sometimes  amnesic.  The  exciting  cause 
of  the  seizure  is  usually  resentment  at  a  real  or  imagined  injury,  loss  of  money, 
anticipation  of  disgrace  or  punishment  on  account  of  some  misdeed,  the 
sight  or  odor  of  blood  or  a  marital  grievance  or  infelicity.  During  the  attack 
there  is  entire  absence  of  memory  whijch  is  an  important  point  in  the  differ- 
entiation of  this  condition  from  that  of  latah. 

The  disease  has  been  attributed  to  alcoholism,  opium  smoking  and  relig- 
ious mania  but  while  there  is  indubitably  a  religious  element  in  some  of  the 
cases,  the  two  former  factors  may  be  excluded. 

It  is  the  opinion  of  authorities  that  the  individual  who  is  "running  amok" 
is  not  responsible  for  the  acts  committed  during  the  frenzy. 

ASTASIA-ABASIA. 

Definition.  A  morbid  condition  in  which  the  patient  is  unable  to  stand  or 
to  walk,  while  the  sensation,  muscular  power  and  coordination  of  the  limbs 
remain  normal.  The  affection  is  an  hysterical  functional  neurosis  and  has 
an  aetiology  similar  to  that  of  hysteria.  It  has  been  observed  as  a  sequela  of 
the  acute  infectious  diseases  and  may  result  from  nervous  shock  due  to  trau- 
matism. 

Symptoms.  The  symptoms  t^-pical  of  this  condition  are  total  or  incomplete 
inability  to  stand  or  walk,  while  the  limbs  may  be  used  in  swimming  and  the 
patient  is  able  to  move  them  as  he  lies  in  bed.  There  is,  in  most  patients,  no 
disorder  of  sensation,  no  spasticity,  no  rigidity,  the  power  or  coordination  is 
normal,  and  the  muscles  retain  their  normal  strength. 

In  some  instances  the  patient  may  be  able  to  walk  but  the  gait  is  some- 
what spastic  or  ataxic,  while  in  others  the  limbs  may  imdergo  sudden  flexions 
or  the  patient  may  manifest  a  saltatory  spasm. 

The  prognosis  is  that  of  hysteria  of  the  ordinary  type  and  the  treatment 
is  that  of  this  latter  disease,  the  rest  cure  and  electricity  being  particularly 
indicated. 

TRAUMATIC  NEUROSES. 

Synonyms.  Traumatic  Hysteria;  Erichsen's  Disease;  Railway  Spine; 
Railway  Brain. 

Definition.  An  hysterical  or  neurasthenic  condition  following  nervous 
sliock,  particularly  that  due  to  sudden  severe  traumatism. 

.Etiology.  This  affection  may  be  the  result  of  severe  mental  shock  resulting 
from  participation  in,  or  even  ^\^tnessing,  railroad  accidents,  explosions,  ship- 
wrecks or  other  accidents.  Even  slight  traumatisms,  such  as  may  result  from 
a  slip  upon  the  pavement  or  stairs,  may  cause  it. 


848  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Pathology.  The  morbid  changes  occurring  in  this  disease  are  indefinite. 
Fatal  cases  are  few  but  degeneration  of  the  pyramidal  tracts  has  been  found 
after  spinal  concussion,  and  punctiform  haemorrhages  in  the  brain  and  cord, 
sclerotic  patches  in  the  white  matter  and  sclerosis  of  the  cerebral  vessels  have 
been  described. 

Symptoms.  In  certain  patients  these  are  not  markedly  different  from  those 
of  hysteria  or  neurasthenia  due  to  other  factors.  Those  referable  to  sensation 
are  headache  and  backache,  spinal  tenderness,  numbness  and  tingling  in  the 
extremities;  hemianeesthesia,  with  acliromatopsia  on  the  anaesthetic  side  or 
contraction  of  the  visual  field,  may  occur.  Motor  symptoms  of  various  degrees, 
fibrillary  twitchings  (Rumpf's  sign)  and  even  paralysis  may  be  present.  The 
reflexes  may  be  exaggerated,  differing  in  degree  from  time  to  time. 

In  severe  instances  with  actual  spinal  concussion  symptoms  suggestive  of  or- 
ganic disease  of  the  nervous  system  may  develop.  These  may  appear  early  or 
may  be  gradual  in  their  evolution  and  the  accountable  lesion  has  been  found  post 
mortem  in  certain  cases  in  the  shape  of  a  pachymeningitis.  The  symptoms 
of  such  patients  consist  of  pain  in  the  head,  back  and  other  parts  of  the  body, 
hemianaesthesia  and  areas  of  diminished  cutaneous  sensation  and  of  tenderness, 
loss  of  temperature  sense  and  of  muscular  sense,  the  latter  being  bilaterally 
symmetrical  or  irregular  in  distribution,  disorders  of  smell  and  taste  and 
diminution  of  the  visual  field  with  inequality  of  the  pupils.  Motor  symptoms 
are  of  various  types;  monoplegia  with  or  without  consequent  contracture, 
without  atrophy  and  with  persistence  of  normal  electric  irritability  may  occur 
with  diminution  of  the  cutaneous  reflexes,  the  deep  reflexes  being  increased. 
The  mental  symptoms  are  identical  with  those  of  marked  hysteria. 

Rarely  in  instances  which  have  been  primarily  regarded  as  hysterical  cr  neu- 
rasthenic, true  organic  changes  evidenced  by  such  symptoms  as  optic  atrophy, 
bladder  disturbances,  increased  reflexes,  paresis  and  tremor,  develop.  Such 
may  end  in  death,  the  organic  changes  being  demonstrable  upon  autopsy. 

The  prognosis  as  regards  recovery  is  good ;  few  patients,  however,  are  relieved 
while  litigation  is  in  progress;  even  after  the  decision  has  been  rendered  in 
the  patient's  favor  the  symptoms  may  persist  but  usually  after  the  suit  is 
terminated  gradual  recovery  begins.  Rarely  patents  grow  progressively  worse 
and  melancholic  symptoms  develop,  followed  by  dementia  or  paresis.  In  the 
instances  in  which  organic  changes  develop,  the  prognosis  is  unfavorable. 

Treatment  consists  in  the  employment  of  the  methods  and  means  suggested 
in  the  sections  upon  the  treatment  of  hysteria  and  neurasthenia  (pp.  819 
and  841). 

OCCUPATION  NEUROSES. 

Synonyms.     Professional  Spasm;  Copodyscinesia. 

Definition.     This  term  is  employed  to  designate  a  variety  of  nervous  condi- 


OCCUPATION    NEUROSES.  849 

tions  characterized  by  involuntary  spasm  or  cramp  of  the  muscles  employed 
in  performing  some  frequently  repeated  movement.  The  affection  is  seen 
most  frequently  in  writers  and  here  is  denominated  writer's  cramp  or  scrivener's 
palsy;  similar  conditions  occur  in  telegraphers,  piano-forte  and  violin  players, 
typewriters,  milkers,  seamstresses,  cigarmakers  and  other  tradespeople  who 
continually  perform  the  same  muscular  act  in  carrying  out  their  occupations. 

.Etiology.  While  occupation  neuroses  occur  in  those  of  phlegmatic  tem- 
perament, they  seem  to  be  more  frequent  in  those  of  neurotic  tendency.  Men 
seem  to  be  more  frequently  afiiicted  than  women  though  this  may  be  the  case 
because  the  male  sex  is  more  likely  to  be  employed  in  occupations  in  which 
the  condition  develops.  Writer's  cramp  is  the  most  common  type  of  occupa- 
tion neurosis  and,  according  to  Gowers,  it  is  seen  more  often  in  those  who  employ 
imperfect  methods  in  writing,  using  the  little  finger  or  wrist  as  fixed  points, 
whereas  the  elbow  or  forearm  should  properly  remain  stationary.  Injury 
may  precede  the  onset  of  the  affection. 

Pathology.  No  morbid  changes  typical  of  this  disease  have  ever  been 
described.  Various  theories,  however,  have  been  advanced  to  account  for 
its  occurrence.  Of  these  the  most  probable  is  that  the  affection  is  a  central 
one  and  is  due  to  a  disordered  action  of  the  nerve  centers  which  control  the 
muscular  movements  employed  in  writing.  Atrophy  involving  the  affected 
muscles  is  sometimes  observed. 

Symptoms.  The  first  of  these  to  appear  is  usually  a  cramp  or  spasm,  chiefly 
involving  the  thumb  and  forefinger.  The  pen  may  be  grasped  too  forcibly 
while  the  forefinger  tends  to  slip  off  the  pen,  or  the  thumb  may  be  flexed 
and  adducted.  A  "lock  spasm"  may  occur  in  which  the  pen  can  be  removed 
from  the  grasp  of  the  fingers  only  with  diflSculty.  The  hand  feels  weary 
and  aching;  pain,  sometimes  affecting  the  arm  as  well  as  the  hand,  may  be 
present.  The  patient's  grasp  of  the  pen  may  be  weak  while  the  hand-grip 
remains  normal.  Tremor,  most  frequently  of  the  index  finger,  may  occur, 
sometimes  as  a  precursor  of  atrophy.  Numbness  and  tingling  of  the  hand 
and  forearm  may  be  observed  and  if  a  true  neuritis  is  present  there  is  tender- 
ness along  the  course  of  the  affected  nerve. 

Marked  instances  may  manifest  such  vaso-motor  symptoms  as  glossy  skin,  a 
condition  resembling  that  of  chilblains  or  hyperaesthesia,  while  on  an  attempt 
to  write  the  skin  may  become  hot  and  cyanosed. 

Electric  reaction  in  the  early  stages  remains  unchanged  but  late  in  the 
disease  the  response  of  the  motor  nerve  endings  to  faradism  is  diminished 
while  that  to  galvanism  may  be  increased. 

The  prognosis  in  marked  types  of  the  disease  is  hardly  favorable  as  regards 
complete  recovery  although  rarely  this  may  take  place.     Patients  exhibiting 
sensory  symptoms  are  more  likely  to  recover  than  others  in  whom  these  are 
lacking.     Relapses  are  not  uncommon. 
54 


850  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Treatment.  Prophylaxis  consists  in  the  acquirement  of  a  proper  technique 
in  writing,  as  it  is  probable  that  if  writing  from  the  shoulder  were  in  general 
use,  cases  of  writer's  cramp  would  be  rare.  The  various  appliances  calculated 
to  lessen  the  fatigue  of  writing  are  of  little  use,  and  invention  of  the  typewriter 
has  rendered  all  such  unnecessary.  Fortunately  the  affection  does  not  inter- 
fere with  the  patient's  ability  to  use  this  instrument.  Learning  to  write  with 
both  hands  is  a  way  out  of  the  difficulty  unless  both  become  affected  with  the 
disease;  this  unfortunate  circumstance  may  occiir. 

Rest  of  the  affected  part  is  essential  to  a  cure  and  as  an  adjunct,  attention 
should  be  given  to  the  patient's  general  hygienic  condition.  Fresh  air  and  good 
food  are  necessities  and,  when  indicated,  the  tonics,  iron,  arsenic,  strychnine 
and  codliver  oil,  should  be  employed. 

Electricity  may  be  prescribed  with  benefit,  most  authorities  preferring  the 
galvanic  current;  its  use  should  be  continued  for  months,  a  current  of  four 
milliamperes  being  sufficiently  strong.  The  current  may  be  applied  every 
day  or  two  for  from  five  to  ten  minutes.  Various  methods  of  using  the  current 
have  been  advocated;  the  positive  pole  may  be  applied  to  the  neck  while  the 
negative  is  placed  in  the  supra-clavicular  fossa, being  at  intervals  moved  to  the 
skin  over  the  affected  muscles  and  nerves.  The  current  may  also  be  applied 
to  the  spinal  column,  or  it  may  be  passed  through  the  head.  If  marked  tre- 
mor is  present  the  negative  pole  may  be  applied  to  the  spinal  region  while 
the  positive  is  placed  over  the  nerves  and  muscles  involved.  An  ascending 
current  through  the  affected  arm,  the  negative  pole  being  on  the  forearm 
or  ball  of  the  thumb  and  the  positive  upon  the  neck,  may  be  used.  So  many 
variations  in  the  technique  of  the  electric  treatment  are  employed  by  different 
authorities  that  it  seems  safe  to  suggest  that  it  is  the  fact  that  galvanism  is 
used  that  achieves  benefit  rather  than  that  a  special  method  is  effectual  beyond 
any  other. 

A  weak  faradic  current  is  indicated  when  paralvsis  and  anaesthesia  are 
present. 

Hydrotherapeutic  measures,  massage  and  gymnastic  exercises  are  useful, 
particularly  the  last.  The  most  efficacious  are  those  employed  by  Wolff. 
These  consist  of  active  and  passive  movements,  the  former  are  performed 
as  follows:  The  fingers,  hands,  forearms,  and  upper  arms  are  moved  in 
every  direction  possible,  effort  being  made  to  contract  forcibly  each  muscle 
from  six  to  twelve  times.  The  exercise  should  last  about  half  an  hour,  the 
patient  pausing  after  the  completion  of  each  movement. 

The  passive  movements  are  performed  in  the  same  manner  and  as  each 
is  made  the  operator  offers  opposition.  Both  active  and  passive  movements 
should  be  repeated  two  or  tliree  times  a  day.  Massage,  consisting  especially 
of  percussion  of  the  affected  muscles,  is  given  in  connection  with  this  treat- 
ment.    Re-education  similar  to  that  advocated  in  the  treatment  of  locomotor 


Raynaud's  disease.  851 

ataxia  produces  good  results.     The  patient  is  given  systematic  instruction  in 
holding  the  pen  and  writing. 


VASO-MOTOR  AND  TROPHIC  DISORDERS. 

RAYNAUD'S  DISEASE. 

Synonyms.     Symmetrical  Gangrene  of  the  Extremities;  Local  Asphyxia. 

Definition.  A  vascular  disease  due  to  a  disorder  of  the  vaso-motor  system 
and  characterized  by  three  stages:  (i)  local  syncope;  (2)  local  asphyxia;  (3) 
local  gangrene. 

.Etiology.  The  causation  of  this  condition  is  indefinite  and  obscure. 
The  disease  occurs  less  frequently  in  men  than  in  women  and  is  more  com- 
mon in  individuals  in  early  adult  life.     Children  may  be  affected. 

Pathology.  This  also  is  not  yet  definitely  determined.  Raynaud  suggested 
that  vascular  spasm  is  responsible.  The  asphyxia  occurs  as  a  result  of  dila- 
tation of  the  capillaries  and  minute  veins  with  spasm  of  the  small  arteries  as 
an  additional  influence. 

Symptoms.  Of  these  the  first  remarked  is  a  paleness  of  the  affected  part 
followed  by  loss  of  sensation  and  a  marble-like  whiteness.  The  condition 
simulates  closely  that  due  to  exposure  to  cold  and  affects  chiefly  the  fingers 
or  toes,  and  is  knovni  as  local  syncope.  It  lasts  varying  lengths  of  time  but 
usually  for  only  an  hour  or  so  and  may  occur  following  a  chilling  of  the 
extremities  or  emotional  disturbance.  As  the  reaction  sets  in  the  affected 
parts  become  hot,  reddened  and  painful.  This  is  the  stage  of  asphyxia  and 
may  not  affect  all  the  fingers  at  the  same  time,  one  or  more  of  the  extremities 
may  be  purple  and  livid  while  the  whiteness  of  the  others  persists.  The  ears 
and  the  tip  of  the  nose  may  be  involved  in  this  state  of  asphyxia  and  more 
rarely  the  limbs,  the  skin  over  them  assuming  a  characteristic  mottled  appear- 
ance. With  the  pain  there  may  be  swelling  and  itching.  Chilblains  may 
occur  as  a  complication  of  this  stage.  The  attacks  may  recur  from  time 
to  time,  being  induced  by  exposure  to  cold  or  mental  disturbances,  disappear- 
ing under  the  influence  of  warmth;  the  parts  involved,  may,  after  successive 
attacks,  become  shrunken  and  indurated. 

Few  patients  go  on  to  the  third  stage,  that  of  symmetrical  gangrene.  In 
such,  this  manifestation  succeeds  the  stage  of  asphyxia,  one  or  more  of  the 
fingers  or  toes  becoming  cold,  dry  and  black  in  color,  just  as  in  dry  gangrene. 
A  line  of  demarcation  is  formed  upon  the  skin,  beyond  which  gangrenous 
blebs  may  form  and  finally  there  may  be  sloughing  away  of  the  dead  tissue, 
although  usually  the  loss  of  substance  is  slight.  In  rare  instances  symmet- 
rical patches  of  gangrene  make  their  appearance  upon  the  limbs  or  body 


852  DISEASES    OF    THE    NERVOUS    SYSTEM. 

and  progress  rapidly.  Here  the  outcome  may  be  fatal  within  a  few  days, 
especially  when  the  condition  occurs  in  children. 

An  associated  symptom  which  may  be  met  is  haemoglobinuria  which  may 
accompany  the  local  manifestations  or  take  their  place;  with  this  the  urine 
may  contain  red  blood  cells  and  albumin. 

Other  symptoms  which  have  been  observed  are  stupor  and  partial  uncon- 
sciousness, delusions,  dimness  of  sight,  urticarial  and  erythematous  eruptions, 
scleroderma,  cutaneous  oedema  and  joint  swelling  which  may  result  in  enlarge- 
ment of  the  finger  joints  and  anchylosis.  Peripheral  neuritis  may  occur  as 
well  as  symptoms  of  disturbance  of  the  digestive  system. 

The  prognosis  as  regards  the  preservation  of  life  is  usually  good,  weak 
and  poorly  nourished  children,  however,  may  succumb;  those  whose  powers 
of  resistance  are  good  may  outgrow  the  predisposition  to  the  disease. 

Treatment.  All  individuals  subject  to  this  disease  should  receive  treat- 
ment calculated  to  improve  their  general  condition,  in  the  shape  of  tonics, 
proper  diet,  etc.,  and  should  avoid  exposure  to  cold  and  mental  irritation. 
During  the  attack  the  patient  should  be  kept  in  bed  and  warmly  covered,  the 
limbs  should  be  elevated  and  the  fingers  and  toes  wrapped  in  cotton,  artifi- 
cial heat  being  supplied  in  the  shape  of  hot  water  bottles,  if  necessary. 
Rubbing  the  affected  parts  and  the  employment  of  galvanism  and  faradism 
are  often  beneficial.  Placing  the  limb  in  warm  salt  water  and  applying  one 
electrode  to  the  spine  while  the  other  is  put  into  the  water  has  been  recom- 
mended. Good  results  have  been  reported  from  the  administration  of  glyceryl 
nitrate,  gr.  y^-g  to  jq  (0.0006-0.0012)  tluree  times  a  day.  The  effect  of 
this  drug  is  to  relax  the  vascular  spasm  and  thus  to  improve  the  circulation 
of  the  part.  Shutting  off  the  supply  of  arterial  blood  of  the  limb  by  means 
of  a  tourniquet  or  an  elastic  bandage  for  a  few  minutes  and  then  releasing 
the  constriction  will  result  in  a  reddening  of  the  part  owing  to  the  relaxation 
of  the  vaso-motor  tension  and  is  said  to  be  beneficial.  This  procedure,  in 
severe  t}^es  of  the  disease,  must  usually  be  frequently  repeated  in  order  to 
prove  effectual. 

For  the  severe  pain  salipyrine,  acetphenetidine  and  antipyrine  may  be  admin- 
istered; this  symptom,  may,  however,  require  the  exhibition  of  codeine 
or  morphine;  the  last  must  be  given  with  caution. 

ERYTHROMELALGIA. 

Definition.  A  rare  chronic  disease  characterized  by  pain,  hyperaemia 
and  rise  of  temperature  in  the  part  affected,  this  usually  being  one  or  both 
of  the  lower  extremities.     More  seldom  is  the  upper  limb  involved. 

.Etiology.     The   causation   of   this   affection    is   somewhat  obscure.     It 


ERYTHROMELALGIA.  853 

may  occur  with  certain  spinal  cord  lesions,  and  in  diabetes  mellitus.  Arterio- 
sclerosis seems  to  exert  a  certain  influence  in  its  incidence. 

Pathology.  The  most  constant  morbid  change  is  a  chronic  inflammation 
of  the  arteries  of  the  affected  part.  Weir  Mitchell,  who  first  described  the 
condition,  suggests  that  it  may  be  due  to  a  neuritis  of  the  nerve-endings  while 
another  theory  that  has  been  advanced  is  that  the  lesions  may  be  due  to  irri- 
tation of  the  anterior  horn  cells  of  the  cord. 

Symptoms.  These  are  first  noticed  in  the  ball  of  the  foot  or  the  heel  and 
consist  of  pain  varying  from  vague  discomfort  and  sense  of  weight  to  extremely 
severe  pain;  swelling  may  appear  later,  especially  after  walking  or  standing. 
The  skin  is  reddened,  the  veins  are  dilated  and  there  may  be  visible  arterial 
pulsation.  Rest  and  elevation  relieve  the  symptoms  to  a  considerable  degree. 
The  condition  is  usually  relieved  by  cool  weather,  but  not  in  every  instance. 

The  prognosis  as  to  life  is  favorable  but  the  patient  may  be  subject  to  recur- 
rences at  varying  intervals. 

Treatment.  An  attack  may  be  aborted  by  bathing  the  limb  with  ice  water. 
The  affected  part  should  be  kept  elevated  and  compresses  wet  in  cooling 
lotions  should  be  applied.  Intermittent  hot  and  cold  douches  may  be  em- 
ployed and  the  use  of  the  faradic  current  and  of  systematic  massage  may 
prove  beneficial.  The  pain  may  necessitate  the  administration  of  analgesic 
drugs.  The  patient's  general  condition  should  be  cared  for  and  tonics  should 
be  prescribed  if  necessary. 

ANGIONEUROTIC  CEDEMA. 

Synonym.     Giant  Urticaria. 

Definition.  A  disease  characterized  by  the  sudden  occurrence  of  transient 
localized  oedematous  swelling. 

.Etiology.  Heredity  plays  a  definite  part  in  the  causation  of  this  affection; 
it  seems  to  be  more  common  in  females  than  in  males  in  the  United  States, 
while  the  opposite  is  the  case  in  European  countries.  It  is  more  common  in 
individuals  of  nervous  temperament.  Attacks  may  be  induced  by  exposure 
to  cold  or  by  any  influence  which  reduces  nervous  tone.  The  giant  urticaria 
which  occurs  in  digestive  disturbances  and  in  certain  persons  after  eating 
strawberries,  crabs  or  lobsters  is  probably  a  variety  of  angioneurotic  oedema. 

Pathology.  This  disease  has  been  considered  to  be  due  to  a  neurosis  of 
the  vaso-motor  system  resulting  in  a  dilatation  and  an  augmentation  of  the  per- 
meability of  the  blood-vessels. 

Symptoms.  The  most  frequently  affected  region  is  the  face;  more  rarely 
are  the  hands  and  genitals  involved;  the  condition  may  occur,  however,  in 
any  portion  of  the  body  even  in  the  throat  and  pharynx.  In  the  last  situa- 
tion symptoms  of  asphyxia  result  and  death  has  been  known  to  take  place. 


854  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Digestive  disturbances  such  as  vomiting,  colicky  pains  and  diarrhoea,  may  be 
associated  v^^ith  the  cutaneous  manifestations.  The  area  affected  is  small, 
as  a  rule  being  not  over  two  or  three  inches  in  diameter,  and  varies  in  color 
from  pallor  to  deep  red;  itching  and  burning  sensations  may  be  present  but 
pain  is  rare.  Periodicity  has  been  noticed  in  the  occurrence  of  the  attacks 
and  such  associated  symptoms  as  cardiac  pain  and  haemoglobinuria  have 
been  observed. 

The  disease  is  not  dangerous  to  life  except  when  there  is  involvement  of 
the  air  passages,  but  often  is  very  resistant  to  treatment. 

Treatment.  This  consists  in  the  employment  of  all  measures  which  tend 
to  improve  the  general  condition  of  the  patient  such  as  tonics,  especially  those 
which  affect  the  nervous  system  (phosphorus,  the  glycerophosphates,  quinine 
and  strychnine) ;  in  anasmic  states  arsenic  and  iron  should  be  given  and  under 
all  conditions  the  insistence  upon  proper  diet  and  exercise  in  the  open  air 
is  necessary.  Hydrotherapeutic  measures  are  often  beneficial  and  hypnotism 
has  been  suggested.  This  last  form  of  treatment  should,  however,  be  employed 
with  caution.  The  local  treatment  consists  in  the  application  of  a  10  percent, 
ointment  of  ichthyol  upon  compresses  of  gauze.  The  routine  administration 
of  glyceryl  nitrate  in  doses  of  3-^-5-  to  -j^oi  a.  grain  (0.0006-0.0012)  three 
times  a  day  often  produces  excellent  results.  If,  as  has  been  suggested,  the 
cedematous  condition  is  due  to  an  increased  permeability  of  the  blood-vessels, 
the  treatment  by  dechloridation  (elimination  of  sodium  chloride  from  the  diet) 
may  be  tentatively  prescribed.  When  gouty,  rheumatic  or  purinaemic  con- 
ditions are  present  these  should  be  corrected  by  appropriate  treatment. 

MIGRAINE. 

Synonyms.     Sick    Headache;    Hemicrania;    Bilious  Headache;    Megrim. 

Definition.  A  sensory  nem-osis  characterized  by  headache,  often  unilateral, 
and  sometimes  by  nausea  and  vomiting  and  visual  disorders. 

Etiology.  Heredity  seems  to  exert  a  definite  influence  upon  the  causation 
of  this  disease.  It  occurs  more  frequently  in  women,  especially  those  of 
nervous  temperament,  and  not  seldom  in  those  whose  general  physical  condi- 
tion is  excellent.  Purinasmic  states  predispose  to  its  incidence  and  the  con- 
dition may  be  induced  by  eyestrain,  menstrual  abnormalities,  mental  and 
physical  over-exertion  and  alimentary  disorders.  Predisposing  causes  are 
dental  caries,  and  abnormal  intra-nasal  and  naso-pharyngeal  conditions.  In 
chronic  nephritis  recurrent  migraine  is  not  uncommon. 

Symptoms.  The  onset  of  the  attack  may  be  sudden  or  there  may  be  pro- 
dromata  such  as  dizziness,  ringing  in  the  ears,  spots  before  the  eyes  and  pecu- 
liar visions — the  patient  seeing  imaginary  animals,  for  instance.  Temporary 
hemianopsia  or  scotoma  may  be  observed.     The  pain  soon  makes  its  appear- 


MIGRAINE.  855 

ance.  It  is  usually  frontal  and  on  only  one  side  although  it  may  begin  in 
the  temple  or  occiput.  From  the  original  situation  it  extends  to  one-half 
or  the  entire  head.  In  character  it  is  continuous,  sharp  and  boring.  It  is 
increased  by  noise  and  a  bright  light.  The  appetite  is  lost,  there  is  marked 
nausea  which  may  be  followed  by  vomiting;  the  vomitus  consists  first  of  the 
contents  of  the  stomach — partially  digested  food  or  mucus — and  later  of 
bile.  If  the  vomiting  takes  place  when  the  stomach  is  full  the  pain  is  often 
relieved.  Vaso-motor  manifestations,  such  as  paleness  of  one  side  of  the  face 
which  may  be  followed  by  marked  redness,  may  be  noted.  Arteriosclerosis  of 
the  temporal  artery  on  the  affected  side  is  not  infrequent.  The  rate  of  the 
pulse  is  usually  not  accelerated. 

The  attacks  tend  to  recur  periodically  and  their  duration  is  variable,  last- 
ing from  one  to  three  days.  The  disease  is  an  obstinate  one,  although  the 
prognosis  as  regards  life  is  favorable.  In  certain  instances  the  attacks,  after 
having  persisted  from  youth,  have  disappeared  after  the  age  of  fifty  has  been 
reached  in  males,  and  after  the  menopause  in  females. 

Treatment.  This  should  depend  upon  the  cause  if  this  can  be  ascertained. 
The  diet  and  mode  of  life  should  be  carefully  regulated.  Some  patients  do 
well  upon  an  entirely  vegetable  regimen.  The  bowels  should  be  kept  regu- 
larly open  and  any  digestive  derangement  corrected.  The  eyes  should  be 
examined  by  a  competent  ophthalmologist  and  proper  lenses  prescribed  if 
necessary.  Intra-nasal  and  pharyngeal  conditions  should  receive  appropriate 
treatment.  The  urine  should  be  examined  for  albumin  and  to  ascertain  if 
the  excretion  of  uric  acid  is  sufi&cient.  Should  the  migraine  be  due  to  purin- 
aemic  conditions  these  should  be  treated  (see  p.  263).  In  an£emia  the  admin- 
istration of  iron  and  arsenic  is  indicated.  In  neurotic  patients  all  emotional 
disturbance  should  be  avoided. 

The  treatment  by  means  of  the  bron;iides,  especially  potassium  bromide, 
may  prove  effectual.  This  drug  should  be  given  in  doses  of  i  to  2  drachms 
(4.0-8.0)  per  day  and  continued  if  necessary  for  eight  to  twelve  months. 
The  point  of  toleration  should  be  ascertained  and  the  maximum  dose  given 
for  six  months;  for  the  succeeding  two  to  four  months  the  dosage  should  be 
gradually  diminished  and  at  the  end  of  about  one  year  the  drug  should  be 
stopped.  When  arterial  hypertension  is  present  glyceryl  nitrate  may  be  given 
(xiTT  to  -g^  of  a  grain — 0.0006  to  0.0012).  Here  inhalation  of  amyl  nitrite, 
3  to  5  drops  (0.2-0.33)  niay  abort  an  attack. 

In  patients  in  whom  the  paroxysm  is  attended  by  marked  nausea  and  vomit- 
ing a  thorough  gastric  lavage  followed  by  a  saline  purge,  if  employed  as  soon 
as  any  prodromata  are  noticed,  may  succeed  as  a  preventive  measure. 

During  the  attack  the  patient  should  be  kept  in  bed  in  a  darkened  room; 
the  nausea  may  be  relieved  by  a  cup  of  strong  coffee  or  by  20  to  30 
drops  (1.33-2.0)  of  chloroform.     Hot  or  cold  compresses  should  be  applied 


856  DISEASES    OF    THE    NERVOUS    SYSTEM. 

to  the  head.  The  treatment  of  the  attack  otherwise  consists  in  the  admin- 
istration of  various  analgesics  such  as  salipyrine,  antipyrine,  or  acetphenetidine. 
The  following  formula  may  be  recommended:  I^  acetanilidi,  gr.  iii  (0.2); 
camphorae  monobromatae,  gr.  ii  (0.13);  caffeinae  sodiobenzoatis,  gr.  i  (0.065). 
One  such  powder  may  be  taken  every  three  or  four  hours.  I^  acetphenetidini, 
gr.  viiss  (0.5);  sulphonmethani,  gr.  xv  (i.o);  three  such  powders  may  be 
taken  during  twenty-four  hours.  I^  acetanilidi,  sodium  bicarbonatis,  aa  gr. 
iiss  (0.16);  caffeinae  citratae,  gr.  i  (0.065);  extracti  aconiti,  gr.  -^\  (0.003). 
One  such  tablet  every  three  or  four  hours.  Citrated  caffeine  alone  in  doses 
of  5  grains  (0.33)  or  caffeine  salicylate  in  the  same  dose  may  prove  beneficial. 
This  drug  may  also  be  given  hypodermatically — caffeine  sodiobenzoate,  5 
to  10  grains  (0.33-0.66).  The  extract  of  cannabis  indica  is  considered  by  some 
to  be  the  most  effectual  drug  in  the  treatment  of  migraine.  Its  beginning  dose  is 
J  grain  (0.016).  This  dosage  is  gradually  increased  and  the  administration  of 
the  drug  may  be  continued  for  a  considerable  period.  Aconitine  (Duquesnel) 
may  be  employed  in  doses  of  4^^  to  -j^^j  of  a  grain  (0.00015-0.0003). 
When  heart  weakness  is  present  strychnine  should  be  given  at  the  same 
time.  This  last  drug  is  especially  indicated  in  ophthalmic  migraine.  Tinc- 
ture of  gelsemium  10  to  20  drops  (0.66-1.33)  either  alone  or  with  ^  to 
I  grain  (0.032-0.065)  of  extract  of  cannabis  indica  may  relieve  the  severe 
pain  of  an  attack.  Other  drugs  which  have  been  advocated  in  the  treatment 
of  this  condition  are  ergot  and  guarana.  .  When  the  attack  is  accompanied 
by  emesis  it  is  usually  best  to  administer  medication  hypodermatically  or 
per  rectum.  If  the  pain  is  confined  to  the  course  of  a  certain  nerve  the  over- 
lying skin  may  be  painted  with  a  mixture  of  menthol,  chloral  and  camphor. 
When  less  drastic  measures  fail  a  tape  seton  may  be  passed  tlirough  the  skin 
of  the  nape  of  the  neck  and  allowed  to  remain  in  place  for  two  or  three  months. 

Electricity  may  be  tried,  preferably  in  the  form  of  galvanism;  one  pole 
should  be  applied  over  the  cervical  sympathetic  and  the  other  to  the  nuchal 
region. 

The  employment  of  hydrotherapeutic  measures,  particularly  as  carried 
out  at  one  of  the  various  spas,  may  benefit  certain  patients,  perhaps  rather 
because  of  the  enforced  regularity  of  life  than  because  of  the  baths  themselves. 
A  sojourn  at  Vichy,  Carlsbad,  Evian  or  at  some  of  the  similar  resorts  in  this 
country  may  induce  favorable  results. 

FACIAL  HEMIATROPHY. 

Synonym.    Unilateral  Progressive  Facial  Atrophy. 

Definition.  A  rare  affection  characterized  by  a  gradual  wasting  of  the 
integument,  fatty  tissues,  muscles  and  bones  of  one  side  of  the  face. 

iEtiology.     While  this  disease  is  obscure  in  its  causation  it  is  doubtless 


MYASTHENIA    GRA\T;S.  857 

due  to  a  neurosis  of  the  trophic  functions.  It  is  more  common  in  females 
and  may  occur  secondary  to  the  infectious  diseases  and  in  syringomyelia. 

Pathology.  In  the  only  autopsy  in  which  the  findings  were  such  as  to 
give  evidence  of  the  nature  of  the  affection  an  interstitial  neuritis  of  all  the 
branches  of  the  trifacial  nerve  in  its  terminal  stage  was  found. 

Symptoms.  The  disease  usually  begins  in  childhood  but  in  rare  instances 
may  not  appear  until  adult  life.  The  atrophy  more  frequently  affects  the 
left  side  of  the  face  though  bilateral  involvement  and  patients  who  exhibited 
atrophic  areas  on  the  back  and  arm  of  the  affected  side  have  been  observed. 
At  its  inception  the  wasting  may  affect  a  definitely  localized  area  upon  the 
face  or  may  be  diffuse.  The  skin  and  subcutaneous  tissues  are  first  affected, 
then  the  bones,  particularly  those  of  the  upper  jaw,  and  finally  the  muscles, 
especially  those  of  mastication.  In  the  unilateral  type  the  atrophy  is  dis- 
tinctly limited  at  the  mid-line  of  the  face  and  the  facial  appearance  is 
remarkable,  giving  the  impression  that  the  countenance  is  composed  of  two 
halves  from  different  individuals.  There  may  be  hemiatrophy  of  the  tongue 
and  soft  palate  and  the  teeth  may  fall  out  as  a  result  of  the  wasting  of 
the  gums  and  alveolar  processes;  the  skin  often  changes  in  color  and  the 
hair  of  the  affected  side  falls.  The  orbital  fat  is  involved  in  the  wasting 
process  and  the  eye  is  sunken.  Motor  and  sensory  symptoms  are  rare  but 
spasm  of  the  facial  muscles  and  disordered  sensation  may  be  present. 

The  disease  is  not  dangerous  to  life  but  is  of  chronic  course  and  little  influ- 
enced by  treatment. 

Treatm.ent  consists  in  the  regulation  of  the  patient's  mode  of  life  in  ac- 
cordance with  proper  hygienic  considerations  and  the  systematic  employment 
of  electricity  and  massage. 

MYASTHENIA  GRAVIS. 

Synonym.     Asthenic   Bulbar  Paralysis. 

Definition.  A  condition  characterized  by  progressive  muscular  weakness, 
an  increased  susceptibility  to  fatigue  and  the  presence  of  the  myasthenic 
reaction  of  Jolly — a  tendency  on  the  part  of  the  muscles  to  exhaustion  when 
subjected  to  the  faradic  current. 

Etiology.  In  some  instances  the  affection  has  been  attributed  to  the 
presence  of  indol  in  the  circulating  blood.  This  substance  acts  as  a  poison 
upon  the  muscles  and  is  considered  to  have  a  marked  depressant  action. 

Pathology.  No  definite  pathological  changes  have  been  described  but  in 
certain  instances  lymphoid  infiltrations  of  the  muscular  tissue  have  been 
found. 

Symptoms.  The  disease  occurs  chiefly  in  the  young;  the  muscles  of  the 
eyes, -face,  and  those  of  mastication  and  swallowing  are  first  involved.     Later 


858  DISEASES    OF    THE    NERVOUS    SYSTEM. 

the  affection  spreads  to  the  other  muscles  of  the  body.  Walking  may  become 
difficult  and  a  characteristic  feature  is  a  rapidly  developing  fatigue  following 
the  continued  use  of  the  muscles.  Their  power  is,  however,  recovered  after 
resting.  The  myasthenic  reaction  is  a  pathognomonic  symptom.  Dyspnoea 
may  be  present.  The  course  of  the  disease  is  marked  by  remissions  and 
recoveries  have  been  reported,  but  death  from  exhaustion  or  dyspnoea  is  the 
rule.  Strangulation  while  attempting  to  swallow  has  caused  death.  There 
are  no  atrophic  changes;  spastic  manifestations  and  tremors  are  absent.  In- 
dicanuria  may  be  present. 

Treatment.  If  indolaemia  is  present,  as  evidenced  by  indicanuria,  any 
tendency  to  intestinal  infections  should  be  corrected  (see  section  on  indican- 
uria). Mental  and  physical  rest  are  essential.  Electricity  is  contra-indicated, 
but  massage  may  be  employed.  Strychnine  and  anti-syphilitic  treatment  may 
be  prescribed.  Wlien  disturbance  of  deglutition  is  present  the  patient  may  be 
fed  by  means  of  the  nasal  or  stomach  tube. 

PERIODICAL  PARALYSIS. 

This  is  a  rare  and  interesting  condition  which  occurs  in  certain  families 
or  in  isolated  individuals.  It  is  characterized  by  a  suddenly  appearing 
paralysis  involving  various  groups  of  muscles. 

It  is  probably  due  to  autointoxication  and  in  a  number  of  patients  a  dimin- 
ished excretion  of  kreatinine  occurring  shortly  before  and  at  the  beginning 
of  an  attack,  has  been  observed. 

Symptoms.  The  disease  may  appear  suddenly  and  without  assignable 
cause  in  otherwise  healthy  individuals  or  prodromata  in  the  shape  of  malaise 
and  weakness  in  the  parts  to  be  affected  may  be  noticed.  The  limbs,  especially 
the  legs,  are  chiefly  involved  in  the  paralysis,  although  paralysis  of  the  entire 
body  has  been  observed.  The  cranial  nerves  and  the  special  senses  escape. 
The  reflexes  are  diminished  or  lost  and  faradic  irritability  of  both  muscles 
and  nerves  is  absent.  There  is  usually  no  febrile  movement  nor  acceleration 
of  the  pulse  although  symptoms  of  acute  cardiac  dilatation  may  be  present 
in  some  instances.  After  a  few  hours  or  days  the  paralysis  begins  to  disappear 
rapidly  and  the  patient  quickly  and  entirely  recovers.  Recurrences  are 
frequent,  occiuring  at  intervals  varying  from  a  day  or  two  to  two  or  three 
weeks.     Seizures  are  rare  after  fifty  years  of  age. 

The  paralysis  is  never  permanent  but  patients  sometimes  die  during  an 
attack. 

Treatment.  The  administration  of  the  alkaline  diuretics,  particularly 
potassium  citrate  in  doses  of  20  to  30  grains  (1.33-2.0)  three  times 
a  day  is  said  to  prevent  or  shorten  the  seizures.  This  fact  is  perhaps  in  favor 
of  the  theory  that  the  condition  is  due  to  the  retention  of  toxic  substances 
which  should  be  excreted  in  the  urine. 


ACROMEGALY.  859 

ADIPOSIS  DOLOROSA. 

Synonym.     Dercum's  Disease. 

Definition.  A  rare  condition  characterized  by  the  deposition  of  masses  of 
fat  in  the  subcutaneous  tissue  of  various  parts  of  the  body.  These  masses 
are  tender  and  painful. 

.Etiology.  The  disease  is  one  of  women  in  the  great  majority  of  instances 
and  has  been  considered  to  be  the  result  of  the  early  incidence  of  menopause 
and  of  atrophic  changes  in  the  thyroid  gland.     Its  actual  cause  is  unknown. 

Pathology.  The  fatty  deposits  are  denser  than  normal  fat  tissue  owing, 
to  the  more  abundant  connective  tissue  supporting  framework.  Atrophy 
and  sclerosis  of  the  thyroid  gland  have  been  observed  and  in  one  instance  a 
tumor  of  the  pituitary  body  was  found.  There  may  be  degeneration  of  the 
cutaneous  nerves  with  interstitial  nemritis  and  the  fatty  tissue  may  contain 
haemolymph  glands. 

Symptoms.  As  adult  life  progresses  and  the  patient's  adipose  tissue  in- 
creases it  is  noticed  that  the  fat  is  unevenly  distributed  and  that  burning,  shoot- 
ing pains  occur  referred  to  the  deposits  of  fat;  these  continue  to  increase  in 
size  and  there  is  increasing  weakness  without  signs  of  degeneration  of  the  mus- 
cular system.  Cerebration  may  become  sluggish  but  there  is  no  true  mental 
disturbance.  Irregular  areas  of  h^-persesthesia  or  of  anaesthesia  may  be  ob- 
served and  there  is  frequently  loss  of  the  patellar  reflex. 

The  prognosis.  The  course  of  the  disease  is  chronic  and  recovery  appears 
to  be  impossible.     Death  occurs  from  some  intercurrent  affection. 

Treatment.  The  administration  of  extract  of  the  thyroid  gland  seems  to 
lessen  the  severity  of  the  symptoms  in  certain  instances;  it  is  given  to  the 
point  of  tolerance  and  may  prove  effectual.  The  pains  should  be  controlled 
by  the  coal-tar  analgesics,  antipyrine,  salipvrine  or  acetphenetidine;  codeine 
may  also  be  employed  and,  in  cases  of  absolute  necessity,  morphine. 

ACROMEGALY. 

Definition.  A  chronic  disease  characterized  by  abnormal  growth,  par- 
ticularly of  the  bones  of  the  face  and  extremities. 

etiology.  The  affection  is  rather  more  common  in  women  than  in  men 
and  usually  begins  between  the  ages  of  twenty  and  thirty  years.  Syphilis, 
rheumatism  and  the  infectious  diseases  have  been  considered  as  predisposing 
to  the  condition  but  their  influence  in  its  incidence  is  not  proven.  In  the 
light  of  recent  research  it  is  deemed  probable  that  acromegaly  together  with 
gigantism  and  dwarfism,  occurs  as  a  result  of  a  disordered  function  of  the 
pituitary  body. 

Pathology.  The  bony  hypertrophy  is  uniform  and  symmetrical;  it 
affects  both  the  shafts  and  extremities  of  the  long  bones;  the  maxillae  appear 


86o  DISEASES    OF    THE    NERVOUS    SYSTEM. 

increased  in  size  due  to  enlargement  of  the  antrum  of  Highmore;  this,  with 
a  true  hypertrophy  of  the  mandible,  causes  the  characteristic  increase  in  the 
size  of  the  face.  In  a  very  large  percentage  of  the  autopsies  which  have  been 
made  in  this  disease,  involvement,  usually  hyperplasia,  of  the  pituitary  gland 
has  been  found  which  has  led  to  the  hypothesis  that  the  affection  is  caused 
by  a  functional  derangement  of  this  structure  and  that  the  pituitary  body 
presides  in  some  way  over  skeletal  growth  and  that  the  enlargement  of  the 
bones  in  acromegaly  results  from  a  hypersecretion  of  this  organ.  Persist- 
ence and  enlargement  of  the  thymus  gland  have  been  observed  in  certain 
instances  as  has  also  enlargement  of  the  thyroid  body  as  weU  as  atrophy  of 
this  structvure. 

Symptoms.  The  head  and  face  are  much  increased  in  size,  the  latter 
especially  so;  it  is  much  lengthened  as  a  result  of  widening  of  the  alveolar 
processes  and  there  is  noticeable  separation  of  the  teeth.  The  lower  lip  may 
protrude,  the  neck  seems  to  be  shortened,  the  ears  are  prominent  and  the  alae 
of  the  nose  together  with  the  eyelids,  are  enlarged;  the  tongue  may  be  thickened. 
The  skin  may  be  coarse,  changed  in  color  and  moist  but  is  not  harsh,  thickened 
and  dry  as  in  myxoedema.  The  bones  of  the  limbs  and  especially  of  the  hands 
and  feet,  are  enlarged,  the  fingers  and  nails  are  broad  and  the  hand  possesses 
a  spade-like  appearance.  The  enlargement  is  symmetrical  and  there  is 
no  interference  with  function.  The  increase  in  size  does  not  involve  the 
legs  and  arms  until  late  in  the  disease  when  there  may  be  an  augmentation 
of  their  circumference.  The  scapulae,  ribs,  sternum  and  vertebral  column 
may  be  affected,  kyphosis  being  a  not  unusual  late  symptom.  Muscular 
atrophy  is  sometimes  present;  the  genitals  may  be  enlarged.  Headache  and 
pains  in  the  bones  may  occur,  the  patient  is  lethargic  and  cerebration  is  slow. 
The  voice  may  be  changed  due  to  the  lingual  thickening  and  enlargement 
of  the  laryngeal  cartilages  and  the  special  senses  may  be  dulled.  Ocular 
manifestations  are  frequent,  a  common  early  symptom  being  bitemporal 
hemianopsia.  Optic  nerve  atrophy  is  frequent  and  neuritis  may  be  noted. 
Menstrual  disorders  are  not  unusual  and  early  menopause  may  occur.  The 
patient  may  suffer  from  dyspnoea,  palpitation  and  (Cardiac  hypertrophy  and 
there  may  be  increased  dulness  over  the  manubrium  sterni  due  to  a  persistent 
thymus  gland. 

The  diagnosis  is  usually  easy,  the  bony  enlargement  being  general,  not 
of  the  extremities  of  the  bones  only  as  in  arthritis  deformans  or  of  the  shafts 
alone  as  in  osteitis  deformans.  Congenital  progressive  hypertrophy  or  giant 
growth  affects  one  extremity  or  one  side  of  the  body  only. 

The  prognosis  is  entirely  unfavorable  as  to  recovery  but  life  is  usually 
preserved  for  a  long  period  unless  terminated  by  intercurrent  disease.  Fatal 
instances  of  acromegaly  have  been  observed  which  were  probably  due  to 
pituitary  neoplasm. 


HYPERTROPHIC    PULMONARY    OSTEOARTHROPATHY.  86l 

Treatment  is  unavailing.  Th\Toid  extract  gives  no  definite  results  and 
the  same  may  be  stated  of  extract  of  the  pituitary  gland.  The  headache  and 
pain  in  the  bones  may  be  relieved  by  antipyrine  or  acetphenetidine. 

LEONTIASIS  OSSEA. 

This  is  a  rare  disease  characterized  by  an  enlargement  of  the  cranial  bones 
and  in  some  instances,  of  those  of  the  face.  The  condition  is  the  result  of  an 
hyperostosis  due  to  a  development  of  multiple  osteophytes  in  the  bones  af- 
fected. In  addition  to  the  increase  in  the  size  of  the  bones,  osteomata  may 
appear  upon  the  outer  or  inner  surfaces  of  the  cranial  bones  which  some- 
times may  press  upon  the  subjacent  structures  and  give  rise  to  the  symptoms 
of  tumor.  The  onset  of  the  disease  may  occiir  in  early  life,  sometimes  fol- 
lowing trauma.     There  is  no  known  effective  treatment. 

OSTEITIS  DEFORMANS. 

Synonym.     Paget's  Disease. 

Definition.  A  rare  disease  characterized  by  enlargement  and  softening 
of  the  shafts  of  the  long  bones  and  sometimes  of  those  of  the  spine  and  cra- 
nium, those  of  the  face  being  unaffected. 

The  changes  in  bony  structure  resiilt  in  certain  deformities  such  as  a  trian- 
gular shape  of  the  head,  the  base  being  upward,  and  spinal  ciirvature,  more 
particularly  a  kyphosis  in  the  dorsal  or  cervical  region.  The  head  is  projected 
anteriorly  and  the  legs  may  be  bowed  outward,  anteriorly  or  posteriorly,  the 
hips  and  lower  thorax  are  widened  and  the  abdomen  becomes  lozenge  shaped. 

.Etiology.  The  causation  of  the  disease  is  unknown  but  the  condition 
has  been  considered  to  have  a  possible  relationship  to  acromegaly  or  osteo- 
malacia. 

Pathology.  Microscopic  examination  of  the  bone  structure  reveals  the 
presence  of  a  rarefying  osteitis  associated  with  the  formation  of  new  bony 
lamellae,  some  of  the  Haversian  canals  being  wider  than  normal  while  others 
are  contracted. 

The  symptoms  consist  chiefly  of  the  deformities  resulting  from  the  bony 
enlargements. 

Treatment  appears  to  be  vauleless. 

HYPERTROPHIC  PULMONARY  OSTEOARTHROPATHY. 

Definition.  A  condition  characterized  by  enlargement  of  the  bones  of  the 
hands  and  feet  especially  in  the  neighborhood  of  joints.  Occasionally  the 
ends  of  the  bones  of  the  forearm  and  legs  are  involved.     The  affection  is  usu- 


502  DISEASES    OF    THE    NERVOUS    SYSTEM. 

ally  associated  with  some  pulmonary  lesion  such  as  chronic  bronchitis,  emphy- 
sema, tuberculosis,  empyema,  fibroid  phthisis  or  neoplasm. 

^Etiology.  The  causation  of  the  affection  is  not  definitely  known.  It  is  a 
disease  of  adults  and  has  been  attributed  to  the  toxins  of  the  pulmonary  lesion 
which,  being  taken  into  the  circulation,  bring  about  an  ossifying  periostitis 
by  their  irritant  action;  other  hypotheses  are  that  it  is  due  to  circulatory 
obstruction  and  trophic  nervous  disorders  or  that  the  condition  is  a  benign 
tuberculous  inflammation. 

Pathology  and  symptoms.  The  bones  of  the  head  and  face  are  not  involved. 
There  is  enlargement  of  the  terminal  phalanges  and  the  nails  are  increased 
in  size  and  curved  over  the  finger  ends  causing  the  so-called  clubbed  fingers. 
There  may  be  osteitis  and  thickening  of  the  shafts  of  the  long  bones  and  joint 
effusions;  spinal  curvatures  are  rare  but  may  result  from  direct  extension  of 
the  pulmonary  disease.  Muscular  atrophy  from  disuse  may  be  present. 
The  course  of  the  affection  is  protracted  and  its  development  is  slow  although 
in  occasional  instances  the  evolution  of  the  deformities  is  moderately  rapid. 
Pain  and  tenderness  are  infrequently  observed. 

Treatment.  The  deformities  cannot  be  influenced  by  medication.  The 
chief  indication  is  to  combat  the  co-existing  pulmonary  condition  by  ap- 
propriate means. 

SCLERODERMA. 

Synonym .     Dermatosclerosis. 

Definition.  A  chronic  condition  characterized  by  local  or  generalized 
stiffening  and  induration  of  the  skin. 

There  are  two  types  of  the  disease;  the  diffuse  and  the  circumscribed,  the 
latter  being  also  known  as  morphoea. 

.Etiology.  The  circumscribed  type  is  the  more  common  and  may  be  of 
trophoneurotic  causation.  The  diffuse  form  is  probably  of  similar  origin 
and  seems  to  be  predisposed  to  by  exposure  and  attacks  of  rheumatism.  It 
may  develop  as  a  complication  of  exophthalmic  goitre  or  in  association  with 
Raynaud's  disease.  Both  forms  occur  more  frequently  in  women  and  usually 
in  middle  adult  life. 

Pathology.  There  is  no  change  in  the  epidermis;  there  is  an  increase  in 
the  connective  tissue  of  the  corium  and  an  hyperplasia  of  the  subcutaneous 
connective  tissue  probably  resulting  from  arterial  changes.  The  glands  of 
the  skin  are  not  altered  but  there  may  be  atrophy  of  the  thyroid  gland.  In 
the  diffuse  form  of  the  disease  the  cutaneous  changes  are  general  while  in 
morphoea  they  are  localized. 

Symptoms.  The  diffuse  type  of  scleroderma  is  rarer  and  more  obstinate 
than  the  circumscribed.     The  skin  of  the  extremities,  of  the  face,  of  the  chest 


AINHUM.  863 

or  of  the  neck  is  first  affected;  the  skin  becomes  firm  and  tense  and  upon 
movement  a  peculiar  stiffness  is  observed;  later  it  becomes  brawny  and  indu- 
rated and,  while  sometimes  its  normal  appearance  persists,  it  is  more  often 
smooth  and  glossy.  Ultimately  the  skin  becomes  so  hard  and  inelastic  that 
flexion  of  the  joints  which  are  covered  by  the  affected  tissue  is  difficult  or 
impossible.  When  the  face  is  involved  the  expression  is  lost  and  the  lips 
may  become  immobile.  Cyanosis  of  the  extremities  may  occur  due  to  vaso- 
motor disturbances  and  pigmentation  resembling  that  of  Addison's  disease 
may  be  observed.  When  the  condition  is  not  general  it  tends  to  symmetry 
of  distribution  which  the  circumscribed  type  of  the  disease  does  not.  The 
course  of  the  affection  is  chronic,  months  often  being  required  for  its  develop- 
ment. While  it  may  persist  in  statu  quo  for  years,  at  times  it  gradually  disap- 
pears leaving  no  trace. 

Sclerodactyly  may  be  considered  as  related  to  scleroderma.  Here  the  fingers 
become  atrophied  and  their  skin  is  thickened  and  glossy;  the  nails  are  dis- 
torted and  pigment,  ulcerations  and  excoriations  may  appear  over  the  joints. 

The  circumscribed  form  or  morphoea  is  characterized  by  the  appearance 
of  brawny,  waxy  patches  upon  the  skin,  usually  of  the  breasts  or  neck,  some- 
times along  the  course  of  the  nerves.  Hyperaemia  with  pruritus  may  be  an 
initial  symptom,  later  there  may  be  deposition  of  pigment  or  entire  loss  of 
coloring  matter  (leucoderma).  The  patches  often  develop  and  spread  with 
rapidity  and  there  may  be  sensory  disturbances.  While  the  cutaneous  mani- 
festations may  persist  for  only  a  few  weeks,  at  other  times  they  remain  for 
years;  ultimately,  however,  they  usually  disappear. 

Treatment.  The  only  medication  that  seems  to  exercise  any  effect  over 
the  condition  is  thyroid  extract.  Instances  have  been  reported  in  which 
much  benefit  was  derived  from  its  administration.  It  may  be  necessary  to 
continue  its  use  for  years.  Tonics  should  be  given,  iron,  codliver  oil  and 
especially  arsenic.  The  salicylates  and  phenyl  salicylate  in  doses  of  10  to  15 
grains  (0.66  to  i.o)  three  times  daily  have  been  recommended  and  the  use 
of  the  galvanic  current  upon  the  lesions  has  been  advised. 

The  patients  should  be  kept  warmly  clothed  and  protected  from  exposure. 
Warm  baths  and  massage  of  the  affected  parts  with  bland  oils  or,  in  protracted 
and  obstinate  instances,  with  oil  of  turpentine  well  diluted  with  olive  oil 
should  be  employed  to  lessen  the  stiffness  of  the  skin. 

AINHUM. 

Definition.  A  trophoneurosis  characterized  by  the  development  of  a  furrow 
in  the  digito-plantar  fold  and  finally  resulting  in  amputation  of  the  toe. 

.Etiology.  This  disease  affects  the  dark  skinned  races  almost  exclusively. 
It  is  not  infrequent  in  Brazil,  India  and  Africa  and  has  been  observed  in  the 


864  DISEASES    OF    THE    NERVOUS    SYSTEM. 

United  States.     Traumatism  may  act  as  a  predisposing  factor.     No  specific 
cause  is  known. 

Pathology.  Microscopically  a  constricting  band  of  fibrous  tissue  is  seen 
about  the  base  of  the  toe;  this  gradually  becomes  tighter,  the  member  swells, 
becomes  disintegrated  witliout  suppuration,  and  finally  falls  off. 

Symptoms.  The  little  toe  is  most  often  involved.  The  furrow  is  first 
seen  upon  its  inner  aspect,  increases  laterally,  becomes  deeper,  the  toe  swells 
and  burning  pain  may  extend  to  the  foot  or  up  the  leg.  Finally  the  swelling 
disappears  and  the  toe  is  spontaneously  amputated  leaving  a  dry  scab  behind. 
Constitutional  manifestations  are  wholly  wanting. 

The  prognosis  is  favorable  as  regards  recovery  although  the  process  may 
persist  for  a  number  of  years. 

Treatment  is  entirely  surgical.  Early  in  the  affection  the  constricting 
band  should  be  severed.  After  the  toe  has  degenerated  amputation  will 
hasten  recovery. 


MYOSITIS.  865 


CHAPTER  XI. 

DISEASES  OF  THE  MUSCULAR  SYSTEM. 

MYOSITIS. 

INFECTIOUS  MYOSITIS. 

Synonym.     Suppurative  Myositis. 

Definition.  An  acute  or  subacute  inflammation  of  striped  muscle  due  to 
an  infectious  agent. 

.Etiology.  The  disease  has  been  observed  most  frequently  in  Japan  and 
seems  in  most  cases  to  be  due  to  infection  v^ith  the  staphylococcus  pyogenes 
aureus,  while  more  rarely  the  albus  is  found  co-existing  or  the  streptococcus 
seems  to  be  responsible  for  the  condition. 

Pathology.  The  distinctive  lesions  seem  to  be  firmness,  brittleness  and 
fatty  degeneration  of  the  muscles  involved,  serous  infiltration  and  hyper- 
plasia of  the  inter-muscular  septa.  Abscesses  may  be  present  in  the  substance 
of   the  affected  muscles  and  an  irregular  erythematous  rash  is  often  seen. 

Symptoms.  The  muscles  of  the  limbs  are  more  usually  affected  but  those 
of  the  body  and  the  heart  muscle  may  participate  in  the  infection.  The  onset 
of  the  disease  is  usually  sudden  with  marked  febrile  movement  and  prostra- 
tion. There  is  swelling  of  the  muscles  with  slight  oedema  and  an  erythemat- 
ous rash  upon  the  body  and  limbs.  There  is  pain  in  the  muscles,  motion 
increases  this  symptom.  Parassthesis  may  occur  in  lieu  of  the  pain.  Later, 
abscesses,  vnth  their  ordinary  symptoms,  may  form  in  the  substance  of  the 
muscles  and  pyaemia  may  follow. 

Instances  have  been  reported  in  which  atrophy  of  the  affected  muscles  oc- 
curred but  these  may  have  been  instances  of  acute  progressive  muscular  atrophy. 

The  disease  has  been  called  pseudo-trichinosis  from  its  resemblance  to 
that  affection. 

The  course  of  infectious  myositis  lasts  from  one  month  to  a  year  or  more. 

Polymyositis  Haemorrhagica  is  the  name  given  to  form  of  myositis  differ- 
ing little  from  the  preceding  except  for  the  fact  that  during  its  course  haemor- 
rhages between  the  muscle  fibres  occur  and  circulatory  symptoms  resulting 
from  involvement  of  the  heart  muscle  are  observed. 
SS 


866  DISEASES    OF    THE    MUSCULAR    SYSTEM. 

OSSIFYING  MYOSITIS. 

Synonym.     Myositis  Progressiva  Ossificans. 

This  is  a  rare  disease  characterized  by  a  calcification  of  the  muscles.  It 
is  seen  most  often  in  males  and  is  likely  to  begin  about  the  age  of  puberty. 
Its  course  is  very  protracted  and  finally  most  of  the  muscles  may  become 
involved.  The  process  begins  with  fever  and  swelling  and  redness  of  the 
muscles  affected;  induration  persists  after  the  acuity  of  the  condition  has 
disappeared  and  the  indurated  areas  are  finally  transformed  into  bony  sub- 
stance. Entire  muscles  may  become  ossified.  Theories  advanced  to  account 
for  the  process  are  that  the  bone  development  originates  from  the  periosteum 
or  that  the  bone  develops  according  to  Cohnheim's  law  of  foetal  inclusion  and 
is  a  true  osteoma.     Traumatism  seems  to  be  an  exciting  cause. 

Treatment.  This  consists,  in  all  varieties  of  myositis,  in  relieving  the  symp- 
toms as  they  arise.  The  abscesses  in  the  suppurative  type  should  be  opened 
and  drained  and  the  bony  growths  of  the  ossifying  form  may  be  excised  if 
necessary. 

MUSCULAR  DYSTROPHIES. 

PSEUDO-HYPERTROPHIC  PARALYSIS. 

Synonyms.  Lipomatosis  Luxurians  Muscularis;  Atrophia  Musculorum 
Lipomatosa. 

Definition.  A  paralj'tic  condition  of  the  muscles  associated  with  atrophy 
which  is  obscured  by  hyperplasia  of  the  interstitial  fatty  tissue. 

.Etiology.  Heredity  is  the  only  recognized  causal  factor  and  is  of  consider- 
able influence.  The  disease  is  one  which  affects  children  chiefly  and  boys 
more  than  girls.  It  is  usually  transmitted  through  the  mother  although  she 
may  not  have  been  herself  afflicted.  It  is  often  seen  in  several  successive 
generations  and  may  occur  in  several  individuals  in  the  same  generation. 
It  usually  develops  before  puberty  but  may  appear  as  late  as  the  twenty-fifth 
year  or  beyond  that  age. 

Pathology.  The  nervous  system  is  seldom  affected,  the  chief  lesion  being 
in  the  muscles  themselves.  The  muscle  fibres  first  are  increased  in  size,  their 
nuclei  become  more  numerous  and  the  connective  tissue  is  increased.  Later 
the  muscle  fibres  atrophy  and  become  fissured,  the  connective  tissue  becomes 
much  hvpertrophied  and  there  is  marked  increase  in  the  fatty  tissue  between 
the   muscle  fibres. 

Symptoms.  The  symptoms  of  the  paralysis  appear  before  the  evidences  of 
the  pseudo-h}^ertrophy.  The  child  is  unsteady  upon  his  legs,  the  movements 
are  clumsy,  especially  so  in  jumping  and  in  ascending  stairs.     Examination 


JUVENILE  MUSCULAR  DYSTROPHY.  867 

reveals  what  seems  to  be  an  enlargement  of  certain  muscles;  the  pseudo-hy- 
pertrophy being  especially  evident  in  the  calves  and  later  in  the  extensors  of 
the  leg,  the  glutei  and  the  lumbar  muscles;  those  of  the  upper  extremity  are 
seldom  affected  save  the  deltoid  and  triceps.  Walking  becomes  difficult, 
and  the  characteristic  vi^addling  gait  with  shoulders  thrown  back,  abdomen 
protruded,  and  the  lumbar  lordosis  accentuated,  is  evident;  the  nates  are 
prominent  and  the  feet  far  apart.  As  the  legs  are  raised  the  feet  drop  because 
of  weakness  of  the  dorsal  flexors  of  the  foot.  A  very  characteristic  symptom 
is  elicited  by  placing  the  child  on  the  floor  and  bidding  him  to  rise.  He  first 
gets  on  all  fours,  rises  to  his  feet  by  drawing  his  arms  along  the  floor  and  assumes 
an  erect  position  by  climbing  his  own  legs  by  drawing  the  hands  up  the 
limbs  until  one  knee  is  reached,  then  with  this  as  a  vantage  point  he  raises 
the  body,  then  grasping  the  other  knee  forces  himself  into  the  erect  position. 

Palpation  reveals  the  fact  that  while  the  size  of  the  muscles  is  large  their 
consistency,  instead  of  being  normally  firm,  is  soft  and  flabby.  True  atrophy 
of  some  muscles,  especially  of  those  of  the  arm,  without  the  replacement  of 
their  lost  substance  by  fat,  may  be  present. 

There  is  no  sensory  disturbance,  the  sphincters  are  not  affected  and  the 
mentality  is  usually  unimpaired.  The  electrical  irritability  of  the  muscles 
is  less  acute  than  normal  because  of  the  loss  of  muscle  substance  but  the 
reaction  of  degeneration  is  absent;  the  knee  jerk  is  sometimes  lost  and  there 
may  be  mottling  of  the  skin,  especially  over  the  legs. 

The  prognosis  is  grave,  the  patient  seldom  living  to  grow  up. 

JUVENILE  MUSCULAR  DYSTROPHY. 

This  type  of  dystrophy  is  less  frequent  than  the  preceding  affection  and  oc- 
curs in  slightly  older  subjects  although  found  as  a  rule  before  the  age  of  twenty. 
Heredity  plays  the  same  part  in  its  eetiology  as  it  does  in  that  of  pseudo-hy- 
pertrophic  paralysis.  The  disease  begins  usually  in  the  arms  and  shoulders 
and  involves  the  pectorales,  trapezius,  latissimus  dorsi  and  triceps;  later  the 
glutei,  the  quadriceps  extensor,  the  peronei  and  tibialis  anticus  are  affected. 
More  rarely  the  latter  muscles  are  first  attacked;  the  muscles  of  the  hands 
and  feet  are  not  affected  although  muscles  of  the  limbs  other  than  those  men- 
tioned may  finally  participate  in  the  disease,  and  certain  groups  are  likely  to 
be  the  subject  of  a  true  or  pseudo-hypertrophy.  When  the  serratus  is  involved 
there  is  a  projection  of  the  scapula  which  is  quite  typical. 

The  gait  is  waddling  and  locomotion  may  finally  become  impossible. 
Bulbar  symptoms  are  rarely  seen;  the  atrophy,  however,  may  involve  the 
diaphragm  and  cause  death.  The  course  of  the  disease  is  protracted,  Erb 
giving  thirty-eight  years  as  its  longest  limit,  and  the  prognosis  is  distinctly 
unfavorable. 


DISEASES    OF    THE    MUSCULAR    SYSTEM. 

MUSCULAR  DYSTROPHY  OF  THE  LANDOUZY-DEJERINE  TYPE. 

This  affection  is  also  termed  Juvenile  Palsy  of  the  Facio-scapulo-humeral 
Type  and  is  hereditary  in  the  same  sense  as  are  the  two  preceding  diseases. 
It  may  begin  as  late  as  the  thirtieth  year  of  life  and  is  characterized  by  a 
muscular  wasting  involving  primarily  the  facial  muscles.  The  eyes  cannot 
be  entirely  closed  and  phonation,  whistling  and  laughing  are  difficult.  The 
facial  expression  (/cae5  myopathique)  is  characteristic,  the  eyes  being  partly 
closed,  the  cheeks  hollowed  and  the  upper  lip  dependent  (the  tapir  mouth). 
There  are  no  fibrillary  contractions  and  the  electrical  reaction  is  unchanged. 
The  masseters  and  temporals,  the  internal  muscles  of  the  eye  and  those  of 
the  forearm  and  hand  are  not  affected. 


MUSCULAR  ATROPHY  OF  THE  PERONEAL  TYPE. 

This  form  of  muscular  atrophy  begins  late  in  childhood  or  even  after  puberty. 
Heredity  is  a  factor  in  its  causation  and  it  is  met  more  often  in  males.  The 
muscles  on  the  anterior  surface  of  the  leg,  the  extensor  longus  hallucis,  exten- 
sor communis  digitorum  and  the  peronei  are  first  involved;  pes  equinus  or 
equino- varus  may  result;  the  calf  muscles  may  become  affected  later  in  the 
disease  and  after  many  years  those  of  the  hands  and  forearms.  Fibrillary 
contractions  are  present  and  the  reaction  of  degeneration  and  various  sensory 
and  vaso-motor  disturbances  may  occur,  the  affection  thus  differing  from 
the  previously  described  types  of  muscular  dystrophy. 

In  this  disease  peripheral  nerve  degeneration  and  ascending  degeneration 
of  the  posterior  columns  of  the  cord  have  been  made  out  post-mortem  and  in 
view  of  these  findings  the  condition  may  be  considered  as  the  result  of  a  neuritis. 
Its  course  is  chronic  and  little  can  be  done  in  the  way  of  treatment  other  than 
to  correct  the  deformities  by  means  of  apparatus  or  operations. 

The  treatment  of  the  various  types  of  muscular  dystropy  is  most  unsatis- 
factory but  the  measures  suitable  in  progressive  spinal  muscular  atrophy 
(see  p.  757)  may  be  employed.  The  general  health  should  be  considered, 
exercise  in  moderation  prescribed  and  massage  of  the  affected  muscles  with 
oil  is  indicated.  Electricity  may  be  beneficial.  After  the  patient  becomes 
bedridden,  care  should  be  taken  to  prevent  contractures  and  bed-sores. 


PSOROSPERMIASIS.  869 


CHAPTER  XII. 

PARASITIC  DISEASES. 

PSOROSPERMIASIS. 

The  psorosperms,  sporozoa  or  cytozoa,  are  classed  among  the  lowest  forms 
of  the  protozoa.  These  organisms  are  very  common  in  the  invertebrates  and 
are  not  very  rare  in  mammals.  Of  the  psorosperms  the  coccidium  ovijorme 
or  cuniculi  and  the  coccidium  hominis  are  the  most  important.  The  former 
produces  in  the  rabbit  a  condition  characterized  by  the  development  of  whitish 
nodules  in  the  liver  which  vary  in  size  and  are  due  to  circumscribed  dilata- 
tions of  the  bile  ducts.  In  man  a  similar  condition  (Internal  psorospermiasis) 
may  result  in  which  there  may  be  hepatic  tenderness  with  chills,  fever,  prostra- 
tion, stupor  and  finally  coma;  the  nodules  in  the  liver  are  sometimes  palpable. 
After  death  whitish  growths  have  been  found  in  the  peritonaeum,  pericardium, 
liver,  spleen  and  kidneys. 

The  parasites  have  also  been  observed  in  the  kidneys,  ureters  and  intestine. 
In  the  former  instance  frequent  urination  of  bloody  urine  has  been  noted  and 
obstruction  of  the  ureter  with  resulting  hydronephrosis  has  been  described. 
Intestinal  psorospermiasis  causes  gastro-enteric  irritation  with  increasing 
prostration  until  the  patient  may  lapse  into  the  t}^hoid  condition. 

External  psorospermiasis  is  said  to  occur  and  ischaracterizedby  a  hard, 
crusty,  papular  eruption  upon  the  face,  abdomen,  lumbar  region  and  groin; 
later  the  papules  tend  to  become  confluent.  The  sporozoa  are  found  in  the 
cutaneous  lesions  in  this  form  of  the  condition  as  well  as  in  those  of  cutaneous 
carcinoma  and  Paget 's  disease.  Whether  these  organisms  have  any  relation 
to  the  causation  of  these  latter  is  undecided.  In  so-called  dermatitis  coccid- 
ioides  bodies  resembling  psorosperms  have  been  found  to  be  blastomyces. 

Psorosperm  infection  reaches  man  upon  such  vegetables  as  spinach,  lettuce, 
cabbage,  etc.,  which  are  eaten  uncooked  and  are  liable  to  contamination  by 
the  excreta  of  lower  animals  in  which  the  affection  occurs,  consequently  the 
condition  may  be  in  great  measure  prevented  by  proper  attention  to  the 
cleaning  of  green  vegetables. 

Treatment.  The  injection  of  i  to  1000  to  i  to  5000  solution  of  quinine 
has  been  suggested  but  it  can  hardly  be  effectual  unless  the  medicament 
comes  into  contact  with  the  parasite  in  the  intestine.  The  treatment  of 
psorospermiasis  is  otherwise  symptomatic. 


870  PARASITIC    DISEASES. 

Other  protozoa  which  cause  disease  in  man  are  the  amoeba  coli  and  the 
Plasmodium  malaruB.  These  have  been  considered  in  the  section  upon  the 
infectious  diseases. 


DISTOMIASIS. 

Synonym.    Trematodiasis. 

Different  forms  of  distomata  or  flukes  are  found  in  various  situations  in 
the  human  body. 

Distomiasis  of  the  liver  is  due  to  infection  vs^ith  one  of  the  liver  flukes  (Dis- 
tomata). These  organisms  are  of  the  family  Fascolida  of  which  five  species 
have  been  found  in  the  human  system.  The  most  common  is  the  liver  fluke 
(jasciola  hepatica)  which  inhabits  the  bile  passages  of  ruminants,  and  particularly 
those  of  the  horse,  rabbit,  sheep,  goat  and  ass.  The  eggs  of  the  fluke  escape 
in  the  intestinal  evacuations  of  these  animals  and  under  favorable  conditions 
embryos  extrude  from  these  ova  which  are  ingested  by  snails  where  they 
undergo  further  development  and  are  finally  cast  off  to  attach  themselves  to 
certain  water  plants  and,  with  these,  are  eaten  by  animals. 

Symptoms.  When  present  in  large  number  in  the  human  bile  ducts  the 
flukes  cause  an  irregular  diarrhoea  which  at  first  may  be  bloody,  the  liver  is 
enlarged  and  jaundice  may  be  evidenced  at  intervals.  The  patient  may  com- 
plain of  pain;  there  is  seldom  any  marked  febrile  movement.  The  affection 
is  a  chronic  one  and  finally  anasmia  and  emaciation  appear  with  ascites  and 
general  oedema.  Temporary  amelioration  of  the  symptoms  may  take  place 
but  permanent  recovery  is  very  rare,  the  disease  ultimately  resulting  fatally. 
An  endemic  type  of  hepatic  distomiasis  occurs  in  Japan  from  which  children 
are  the  chief  sufferers.     The  ova  are  easily  demonstrated  in  the  fasces. 

Treatment  consists  in  combating  the  symptoms  as  they  arise.  Phenyl 
salicylate  in  large  doses,  male  fern  and  naphthalene  have  been  suggested. 

Pulmonary  distomiasis  due  to  the  distoma  pulmonale  or  lung  fluke  is  occa- 
sionally observed.  This  form  of  fluke  has  been  found  in  the  lungs  of  the 
pig,  dog,  cat,  and  tiger.  It  is  believed  to  enter  the  human  body  with  drinking 
water  and  is  a  parasite  8  to  16  mm.  in  length,  4  to  6  mm.  in  width 
and  2  to  4  mm.  in  thickness.  The  most  typical  symptom  of  its  pres- 
ence is  haemoptysis  which  may  be  mistaken  for  a  manifestation  of  pul- 
monary tuberculosis;  there  is  also  an  intermittent  cough  with  sputum  resem- 
bling that  of  infectious  pneumonia.  Cerebral  metastases  may  occur  with 
paroxysms  of  Jacksonian  epilepsy.  The  eggs,  which  may  be  found  in  the 
sputum,  are  dark  brown,  thick-shelled,  operculated  and  are  from  80  to  100  n 
long  and  from  40  to  60  n  broad. 

The  prognosis  of  the  condition  depends  upon  the  general  condition  and 


DISTOMIASIS.  871 

age  of  the  patient,  the  presence  of  compHcations,  especially  pulmonary  tuber- 
culosis, and  the  number  of  the  parasites  in  the  lungs. 

Prevention  of  this  condition  may  be  accomplished  by  boiling  drinking 
water  and  destroying  the  ova  in  the  sputum  by  disinfection. 

Treatment  is  symptomatic. 

Distomiasis  of  the  blood  or  Bilharziosis  is  the  result  of  infection  with  the 
blood  fluke  or  Bilharzia  hcematobium  {schistosomum  hcBmatohium).  This 
organism  is  a  narrow  worm,  the  male*  being  from  4  to  15  mm.  long,  while  the 
female,  which  is  generally  carried  by  the  male  in  a  gynascophorous  groove, 
is  longer,  being  about  20  mm.  in  length.  The  blood  fluke  is  common  in 
Egypt  and  other  parts  of  Africa  and  is  believed  to  effect  entrance  through  the 
skin  of  persons  who  bathe  in  the  rivers  in  which  it  is  present  in  great  num- 
bers, and  upon  drinking  water  or  upon  infected  food  such  as  edible  water 
plants. 

The  males  with  the  females  seek  the  bladder  and  rectum;  the  latter  lay  their 
eggs  in  the  tissues  but  these  travel  to  other  parts,  some  being  discharged  with 
the  urine  and  faeces  while  others  which  are  retained  produce  irritation,  and 
connective  tissue  changes  and  sometimes  vesical  and  rectal  papillomata;  in 
other  instances  they  become  the  nuclei  of  calculi. 

Symptoms.  The  blood  flukes  may  cause  no  serious  disturbance,  at  times 
being  present  for  long  periods  without  resulting  harm;  usually,  however, 
their  presence  is  associated  with  perinseal  discomfort,  vesical  irritability, 
pain  on  urination  and  bloody  urine;  when  the  parasites  are  harbored  in  the 
rectum  there  is  tenesmus  with  stools  containing  mucus  and  blood;  rectal  ulcer- 
ations and  papillomata  may  result  in  marked  infections.  The  ova  mav  be 
found  in  the  discharges  from  both  bladder  and  rectum. 

Such  complications  as  vesical  and  renal  calculi,  perinaeal  fistulse  and  peri- 
urethral abscesses  may  occur.  The  loss  of  blood  may  result  in  a  moderate 
degree  of  anemia.  There  is  a  distinct  eosinophilia  with  a  corresponding 
diminution  in  the  number  of  polymorphonuclear  leucocytes  in  the  blood. 

The  parasites  may  reach  the  portal  and  mesenteric  veins  but  in  these  situa- 
tions cause  no  especial  symptoms  although  a  thickening  of  the  tissues  about 
the  portal  vessels  (Glissonian  cirrhosis)  is  said  to  occur  at  times. 

The  affection  is  chronic  in  its  course  and  as  stated  may  not  result  in  serious 
damage.  Upon  the  incidence  of  other  infections,  especially  in  children,  the 
symptoms  may  disappear. 

Prevention  of  the  entrance  of  the  fluke  into  the  body  consists  in  avoiding 
possibly  infected  water  and  food  and  not  bathing  in  the  rivers  of  infected 
districts. 

Treatment.  The  employment  of  the  extract  of  male  fern  has  been  sug- 
gested although  there  is  no  known  method  of  destroying  the  parasites  in 
the  blood.     The  haematuria,  rectal  and  vesical  inflammations,  should  receive 


872  PARASITIC    DISEASES. 

appropriate  treatment  and  the  other  symptoms  should  be  combated  as  they 
arise. 

Intestinal  Distomiasis.  A  new  variety  of  blood  fluke,  the  schistosoma  cattoi, 
has  lately  been  described,  the  eggs  of  which  are  smaller  than  those  of  schis- 
tosoma hcBmatobium,  brown  in  color  and  do  not  possess  the  typical  spinous 
extremity.  This  parasite  is  said  to  inhabit  the  blood-vessels  of  the  digestive 
tract  and  to  cause  intestinal  ulceration.  The  ova  are  found  in  the  stools  of 
the  infected  individual. 

The  jasciolopsis  Buskii,  the  mesogonimus  heterophyes  and  the  gastro- 
discus  hominis  may  be  found  in  the  small  intestine.  The  first  and  the  last 
occur  in  British  India  and  the  mesogonimus  has  been  observed  in  Japan  and 
Egypt. 

NEMATODES. 

ASCARIASIS. 

Ascaris  lumbricoides  (the  round  or  maw  worm)  is  one  of  the  most 
common  human  parasites  and  is  found  in  all  parts  of  the  world.  Its  habitat 
is  the  small  intestine.  It  is  most  frequently  observed  in  the  young  but  is  not 
rare  in  adults.  Usually  not  more  than  six  or  eight  are  found  in  one  host  but 
instances  in  which  more  than  a  hundred  have  occurred  have  been  reported. 
Its  body  is  round,  tapering  at  either  end  and  is  marked  with  transverse  stria- 
tions.  It  is  yellowish  or  brownish  in  color;  its  diameter  is  about  that  of  a 
common  goose-quill,  the  male  being  from  four  to  eight  inches  (10  to  20  cm.) 
in  length  while  the  female  is  eight  to  twelve  inches  (20  to  30  cm.)  long.  At 
the  oral  extremity  the  worm  possesses  three  lips,  each  supplied  with  fine 
denticulations,  while  the  caudal  end  terminates  conically,  being  curved  ven- 
trally  in  the  male  and  straight  in  the  female.  The  eggs  are  ellipsoidal  in 
shape  50  to  75  /i  by  40  to  58  fx,  thick-shelled  and  covered  with  an  albuminous 
envelope;  when  found  in  the  stools  they  are  stained  yellowish  from  the  faecal 
matter. 

When  discharged  in  the  intestinal  evacuations  the  ovum  slowly  develops 
in  water  or  moist  earth  and  is  taken  into  the  body  with  food  or  drinking  water; 
the  embryo,  which  has  up  to  this  time  been  enclosed  by  the  envelope  of  the 
egg,  is  now  freed  by  the  action  of  the  juices  of  the  alimentary  tract  and  grows 
to  the  adult  stage  within  four  or  five  weeks. 

The  parasites  usually  remain  in  the  small  intestine  but  may  migrate.  They 
have  been  found  in  the  vomitus,  in  the  faeces,  in  the  bile  ducts  and  in  the  pan- 
creatic duct.  Collections  of  them  may  cause  intestinal  obstruction  and  they 
may  wander  to  the  mouth,  nasal  passages,  into  the  air  passages  when  they  may 
cause  asphyxia  or  pulmonary  gangrene,  or  into  the  Eustachian  tube  and  cause 


ASCARIASIS.  873 

perforation  of  the  tympanic  membrane.  They  frequently  migrate  into  the 
rectum. 

Symptoms.  The  ascarides  may  give  rise  to  no  suspicious  manifestations 
but  their  presence  is  usually  associated  with  intestinal  irritation  and  resulting 
colicky  pain,  dyspepsia,  nausea,  vomiting  and  diarrhoea;  reflex  symptoms 
such  as  restlessness,  disturbed  slumber,  headache,  vertigo  and  even  epileptiform 
and  choreic  attacks  may  be  observed.  Salivation,  itching  of  the  skin,  especi- 
ally at  the  nostrils,  and  anus,  lachrymation,  swelling  of  the  lachrymal  papillae, 
dilatation  of  the  pupils  and  mental  disturbances  may  occur. 

Complications  referable  to  the  presence  of  the  parasite  in  unusual  situations 
have  been  noted.  Among  these  are  jaundice,  due  to  bile  duct  obstruction, 
intestinal  obstruction  and  symptoms  of  asphyxia.  The  worms  have  been 
found  in  perforative  appendiceal  and  perinaeal  abscessess  and  in  inflamed 
herniae. 

The  diagnosis  can  be  positively  made  only  by  demonstrating  the  presence 
of  the  worms  themselves  or  by  finding  the  ova  in  the  faeces. 

The  prognosis  is  wholly  favorable  unless  complications  arise. 

Treatment.  Prevention  consists  in  abstention  from  the  use  of  possibly 
contaminated  food  or  water. 

The  most  efl&cient  anthelmintic  in  ascariasis  is  santonica  which  is  preferably 
administered  in  the  form  of  santonin.  It  may  be  given  in  divided  doses  either 
mixed  with  powered  sugar  or  sprinkled  upon  bread  and  honey  or  jelly; 
for  a  child  of  five  years  three  doses  of  i  grain  (0.065)  ^^ch  at  intervals  of 
four  or  five  hours  are  usually  sufficient.  Lozenges  containing  santonin  are 
not  to  be  commended  for  they  often  fail  to  dissolve.  The  bowels  should  be 
freely  evacuated  by  a  saline  cathartic  or  calomel  shortly  after  the  patient  has 
taken  the  final  dose  of  the  vermifuge  or  the  latter  may  be  given  with 
calomel,  i  grain  (0.065)  of  santonin  to  i  or  2  (0.065-0.13)  of  the  mercurial. 
Untoward  effects  such  as  yellow  discoloration  of  the  urine  or  yellow  vision 
(xanthopsia)  may  follow  the  use  of  santonin  but  they  are  neither  permanent 
nor  serious. 

Sodium  santoninate  should  not  be  employed  since  most  instances  of  san- 
tonin poisoning  have  been  due  to  this  salt. 

Spigelia  is  also  a  popular  remedy  for  the  round  worm  and  is  best  employed 
in  the  form  of  the  unofficial  fluidextract  of  spigelia  and  senna,  the  dose  for  an 
adult  being  2  to  4  drachms  (8.0  to  15.0);  for  a  child  of  two  years  ^  to  i 
drachm  (2.0  to  4.0)  should  be  prescribed. 

Chenopodium  is  considered  an  excellent  vermifuge  in  ascariasis  and  is 
particularly  indicated  in  the  presence  of  intestinal  inflammation  since  it  not 
only  expels  the  worms  but  also  appears  to  benefit  the  irritation  in  the  alimen- 
tary tract.  The  ordinary  dosage  of  the  oil  of  chenopodium  is  3  minims 
(0.2)  which  may  be  administered  in  capsules,  emulsion  or  dropped  upon  lump 


874  PARASITIC    DISEASES. 

sugar.  The  dose  is  usually  repeated  three  times  a  day  before  meals,  for  two 
days,  when  a  cathartic  should  be  ordered. 

Oxyuris  vermicularis  (the  pin-,  thread-,  or  seat-worm)  is  a  very  common 
parasite  and  one  of  almost  universal  distribution.  It  occurs  most  often  in 
children  but  adults  are  sometimes  infected;  large  numbers  are  usually  present. 
The  parasite  very  closely  resembles  a  short  bit  of  white  thread,  the  male  being 
about  ^  of  an  inch  (5  mm.)  long  and  the  female  about  twice  this  length.  The 
oral  extremity  is  supplied  with  a  mouth  possessing  three  retractile  lips.  The 
tail  tapers  to  a  point.  In  color  the  worm  is  white.  The  eggs  are  oval,  flat 
upon  one  side,  thin-shelled  and  colorless  and  about  50  //  by  16  to  20  jx. 

The  oxyuris  inhabits  the  lower  end  of  the  ileum  and  the  ccecum.  They 
wander  freely,  more  usually  downward  to  the  rectum  or  even  into  the  vagina 
but  sometimes  upward  even  as  far  as  the  stomach  whence  they  may  be  vomited. 
When  large  numbers  are  present  in  the  intestine  they  may  form  balls  with 
the  mucous  secretion  of  the  gut;  they  may  be  discharged  with  the  faeces  and 
the  irritation  which  they  cause  often  produces  a  chronic  catarrh  of  the  colon. 

Infection  is  believed  to  take  place  as  follows:  The  ova  with  the  developed 
embryos  inside  are  passed  in  the  faeces  and  become  scattered  over  vegetables 
and  fruit,  which  later  are  to  be  used  as  food,  here  they  may  remain  for  con- 
siderable periods  without  perishing.  The  eggs  also  attach  themselves  to  the 
tissues  and  hairs  about  the  anus  and,  being  removed  thence  by  the  fingers  of 
the  patient,  may  be  transferred  to  his  mouth  or  contaminate  substances  which 
he  may  handle  and  thus  infect  other  individuals.  The  possibility  of  the  ova 
being  transferred  from  fasces  to  food  by  flies  has  also  been  suggested.  Water  is 
said  not  to  transmit  the  infection  for  the  ova  quickly  perish  in  this  medium. 
After  the  ingestion  of  the  eggs  the  worm  reaches  the  adult  stage  in  about  two 
weeks. 

Symptoms.  The  most  characteristic  and  common  of  these  is  anal  pruritus 
which  generally  appears  soon  after  the  patient  retires  at  night;  at  this  time 
the  parasites  migrate  and  often  appear  at  the  anal  orifice.  The  itching  is 
often  extreme  and  the  irritation  caused  by  the  presence  of  the  worms  in  the 
intestine  may  result  in  the  production  of  a  catarrhal  colitis  with  the  exudation 
of  a  considerable  amount  of  mucus.  The  rectal  irritation  also  causes  anal 
prolapse,  frequency  of  urination,  urinary  incontinence,  balanitis  in  the  male 
and  vulvovaginitis  in  the  female;  the  latter  may  also  be  produced  directly 
by  the  entrance  of  the  parasites  into  the  vagina.  The  genital  irritation  may 
induce  the  habit  of  masturbation.  Nervous  manifestations  are  more  rare 
than  with  other  species  of  intestinal  parasites  but  chorea  and  convulsions 
have  been  observed. 

The  diagnosis.  The  worms  may  be  seen  at  the  anus,  to  which  attention 
has  been  directed  by  the  complaint  of  itching;  they  may  also  be  found  in  the 
faeces,  in  which  the  eggs  are  likewise  present. 


ASCARIASIS.  875 

The  prognosis  under  proper  treatment  is  entirely  favorable  although  the 
condition  is  often  obstinate. 

Treatment.  The  parasites  in  the  intestine  above  the  rectum  may  be 
destroyed  by  the  means  suggested  for  the  round  worm  but  the  most  effective 
method  of  treatment  is  that  by  rectal  enemata.  Preliminary  to  the  medicated 
injection  the  rectum  should  be  cleared  of  faecal  matter  and  mucus  by  means 
of  an  enema  of  lukewarm  water  containing  i  drachm  (4.0)  of  borax  to  the 
pint  (500.0).  After  the  bowel  has  relieved  itself  of  this  solution  an  injection 
consisting  of  ^  a  pint  (250.0)  of  i  to  10,000  mercury  bichloride  in  warm 
water  should  be  administered.  The  injection  should  be  given  through  a 
soft  catheter  passed  high  into  the  bowel  and  it  should  be  retained  as  long 
as  possible.  The  procedure  should  be  repeated  every  other  night  until  the 
parasites  and  their  eggs  have  disappeared,  an  enema  of  saline  solution  (0.9 
percent.)  being  given  upon  the  alternate  evening. 

Cleanliness  of  the  parts  about  the  anus  is  an  absolute  essential,  for  no  matter 
how  much  care  is  exercised  the  patient  is  likely  to  contaminate  his  fingers 
by  scratching  and  despite  our  best  endeavors  will  often  re-infect  himself 
by  transferring  ova  to  his  mouth.  After  each  defecation  or  even  oftener  the 
anus  and  perinaeum  should  be  sponged  off  with  i  to  10,000  mercury  bichlo- 
ride solution,  the  anal  folds  being  separated  by  means  of  the  fingers  to  insure 
perfect  contact  of  the  solution  to  all  parts.  On  retiring,  the  anus  may  be 
anointed  with  a  little  mercurial  ointment  or  an  ointment  composed  of  i^ 
drachms  (6.0)  of  mercury  bichloride  to  an  ounce  (30.0)  of  vaseline. 

Injections,  the  patient  being  in  the  knee-chest  position,  of  solutions  of  other 
substances  are  often  efficient;  of  these  an  infusion  of  quassia — ^  pint  (250.0) 
of  the  preparation,  i  to  100  with  cold  water,  to  avoid  extraction  of  too 
much  of  the  bitter  principle — is  often  employed.  Infusion  of  asafoetida, 
aloes  or  garlic,  as  well  as  mixtures  containing  tannic  acid,  vinegar,  oil  of 
eucalyptus  and  camphor,  may  prove  useful.  An  infusion  of  garlic,  with  large 
amounts  of  this  substance  taken  by  mouth,  may  destroy  the  parasites  after 
the  failure  of  the  more  ordinary  means. 

Ascaris  alata  (ascaris  canis,  ascaris  mystax  or  round  worm  of  dogs  and 
cats)  is  a  slender  whitish  or  brownish  parasite,  the  male  from  i  to  i^  inches 
(40.0  to  60.0  mm.)  long,  the  female  about  three  times  this  length.  The 
tail  is  rolled  into  a  spiral  and  upon  either  side  of  the  head  there  is  a  wing-like 
projection.  The  mouth  possesses  three  denticulated  lips.  The  ova  are  nearly 
spherical  and  from  68  to  72  fi  in  diameter.  They  are  contained  in  a  thin 
albuminous  envelope.  The  life-history  of  this  parasite  is  analogous  to  that 
of  ascaris  lumhricoides .  The  ascaris  alata  is  only  occasionally  found  in 
man. 

The  symptoms  and  treatment  are  similar  to  those  of  the  ordinary  round 
worm. 


876  PARASITIC    DISEASES. 

Trichocephalus  dispar  (ascaris  trichiura  or  whip-worm).  This  parasite 
is  about  2  J  inches  (4  to  5  cm.)  in  length  and  possesses  a  body  of  rather  remark- 
able form,  the  anterior  two-thirds  being  extremely  thin  and  hair-like,  while 
the  posterior  one-third  is  thick  and,  in  the  male,  obtuse  and  rolled  into  a  spiral; 
in  the  female  it  is  straight  and  terminates  in  a  blunt  conical  point.  The  ova 
are  oval  and  dark  brown,  their  long  diameter  being  about  0.05  mm. 

Great  numbers  of  this  worm  are  often  found  in  thecoecumand  colon.  It 
is  quite  common  in  Europe  but  is  infrequent  in  the  United  States.  The 
symptoms  are  not  characteristic  and  even  if  the  host  harbors  large  numbers 
of  the  parasite  he  may  exhibit  no  suspicious  manifestations  although  anaemia 
and  diarrhoea  are  sometimes  associated  with  the  presence  of  the  worm.  The 
diagnosis  may  be  made  by  finding  the  eggs  in  the  faeces. 

Eustrongylus  gigas  {dicotophyme  gigas)  is  one  of  the  largest  of  the  nemat- 
odes, the  male  being  about  i  foot  (30  to  40  cm.)  in  length  while  the  female 
is  about  three  times  as  long.  Its  color  is  reddish  and  the  cephalic  extremity 
possesses  a  six-lipped  orifice  bearing  papillae.  The  ova  are  elliptical,  thick- 
sheUed  and  brown,  their  longer  diameter  being  64  to  68  fx.  This  parasite  is 
found  in  the  dog  and  other  animals;  it  is  rare  in  man.  Its  habitat  is  the  pelvis 
of  the  kidney;  as  a  result  of  its  presence  this  structure  becomes  dilated  and 
the  kidney  may  become  reduced  to  a  hydronephrotic  sac  in  which  the  parasites 
are  found  surrounded  by  bloody  urinous  fluid.  The  presence  of  the  worm 
is  demonstrable  only  upon  autopsy.  The  diagnosis  rests  upon  the  demon- 
stration of  the  eggs  in  the  urine.  The  parasite  can  be  removed  by  surgical 
operation  only.  Up  to  the  present  time  only  one  kidney  has  been  found  in- 
volved in  a  single  individual. 

Anguillula  acetici  (the  vinegar  eel)  is  said  to  have  been  found  in  the 
urine  but  its  presence  is  more  probably  due  to  the  fact  that  a  dirty  bottle 
has  been  used  to  collect  this  secretion.  The  anguillulina  prutrejaciens  or 
onion  anguillula,  which  lives  in  this  vegetable,  has  been  found  in  vomited 
fluid. 

Strongyloides  intestinalis.  These  are  small  nematodes  which  are  com- 
monly found  in  the  faeces  of  the  epidemic  diarrhoea  of  tropical  countries. 
They  probably  have  no  especial  influence  in  the  causation  of  the  affection 
but  when  present  in  large  numbers  may  keep  up  the  intestinal  irritation  of  a 
dysentery  due  to  other  causes.  The  parasites  infest  all  parts  of  the  intestinal 
tract  and  may  force  their  way  into  the  bile  and  pancreatic  ducts.  The  worm 
is  frequently  found  in  Indo-China,  East  India,  Africa,  Europe  and  South 
America;  it  has  been  observed  in  the  United  States  in  a  number  of  instances. 
It  causes  no  marked  symptoms  but,  when  present  in  large  numbers,  may 
produce  anaemia.  Stool-disinfection  is  necessary  as  a  preventive  measure 
and  the  worms  may  be  destroyed  by  the  administration  of  the  extract  of 
male  fern. 


ANCHYLOSTOMIASIS.  877 

Acanthocephala  {thorn-headed  worm).  One  or  two  instances  of  human 
infection  by  the  gigantorhynchus  or  echinorhynchus  gigas  have  been  reported 
as  well  as  one  of  echinorhynchus  moniliformis.  In  the  intestine  of  the  pig  the 
gigantorhynchus  is  common,  the  intermediate  host  being  the  cockchafer  or 
the  June  bug. 

ANCHYLOSTOMIASIS. 

Synonyms.  Uncinariasis;  Hook-worm  Disease;  Brick-maker's  Anasmia; 
Miner's  Anaemia;  Egyptian  Chlorosis. 

.Etiology.  The  train  of  symptoms  to  which  the  term  hook-worm  disease 
has  been  applied  is  the  result  of  infection  with  two  types  of  parasite,  the 
anchylostomum  duodenale  of  the  old  world  and  the  uncinaria  Americana 
of  the  western  hemisphere.  Hook-worm  disease  has  been  recognized  since 
the  time  of  the  ancient  Egyptian  writers  but  its  connection  with  the  anchy- 
lostomum duodenale,  which  was  discovered  in  Milan  by  Dubini  in  1838,  was 
not  proven  until  within  comparatively  recent  years. 

The  hook-worm  is  generally  distributed  throughout  tropical  and  sub-tropical 
countries,  being  very  common  in  Egypt  and  frequent  in  the  Philippines,  Porto 
Rico  and  in  the  mining  regions  of  Germany,  Austro-Hungary  and  England. 
In  the  United  States  no  authentic  instances  of  uncinariasis  were  recognized 
as  such  until  1893.  J.n  1902,  Stiles,  to  whom  we.  owe  great  credit  for  his 
work  upon  this  subject,  showed  that  the  .disease  was  very  frequent  in  many 
parts  of  the  country  and  that  to  hook-worm  infection  most  of  the  anaemia 
which  was  so  common  in  the  Southern  States  was  due.  An  anchylostomum, 
the  uncinaria  Americana,  is  the  specific  parasite. 

Both  the  anchylostomum  duodenale  and  the  uncinaria  Americana  possess 
the  same  general  morphological  characteristics.  The  male  is  about  -J  of  an 
inch  (i  cm.)  in  length  while  the  female  is  slightly  larger,  being  about  J  an  inch 
(12  to  15  mm.)  long;  the  length  of  the  foreign  worm  is  slightly  less  than  that 
of  the  native  variety.  The  anchylostomum  duodenale  is  whitish  in  color  or 
flecked  with  brown  spots  posteriorly  if  the  intestine  contains  blood;  there  are 
transverse  striae.  The  body  tapers  toward  the  head  which  is  curved  upon 
the  dorsum  in  the  form  of  a  hook.  The  head  is  provided  with  seven  curved 
teeth.  The  tail  of  the  male  is  abruptly  pointed  while  that  of  the  female  is 
more  tapering  and  finely  pointed.  The  eggs  are  ovoid  in  shape,  colorless 
and  thin  shelled,  their  long  diameter  being  from  50  to  60  [i. 

The  American  hook-worm  has  no  hook-like  teeth  upon  the  oral  rim  but  is 
supplied  with  a  large  ventral  and  smaller  dorsal  chitinous  lip  upon  either  side, 
and  a  larger  and  more  prominent  dorsal  conical  tooth.  The  ova  are  similar 
to  those  of  anchylostoma  duodenale  but  are  larger  being  from  68  to  70  (x  in 
the  longer  diameter. 


878  PARASITIC    DISEASES. 

The  parasite  inhabits  the  duodenum  and  jejunum;  the  eggs  are  passed  in 
the  faeces  and  liberate  their  embryos  in  water  or  moist  earth;  these  develop 
into  larvae  which  may  live  for  an  indefinite  length  of  time  in  the  mud  or  water, 
to  be  finally  taken  into  the  stomach  upon  drinking  water,  food  which  is  con- 
taminated by  the  dirt  under  the  nails  or  upon  the  hands  or  with  earth  which 
is  deliberately  eaten.  In  other  instances  the  larvae  may  enter  the  body  through 
the  skin  and  finally  reach  the  intestine  where  they  develop  into  the  adult 
parasites,  suck  the  blood  from  the  intestinal  wall,  produce  minute  haemor- 
rhages, and,  presumably,  produce  a  substance  which  acts  as  a  poison.  The 
sucked  blood  provides  nourishment  for  the  worm  and  upon  autopsy  the 
parasite  is  found  embedded  in  the  mucous  or  submucous  wall  of  the  intestine 
and  the  intestinal  lining  shows  ecchymoses  open  at  the  centre. 

The  infection  is  most  frequent  in  rural  districts  where  sand  abounds  and 
in  individuals  who  come  into  close  contact  with  the  damp  earth,  such  as 
miners,  excavators,  brick-makers,  etc.  Whites  seem  to  be  more  prone  to 
severe  infections  than  negroes  and  the  most  marked  types  of  the  disease 
occur  in  women  and  young  persons.  Several  instances  in  one  family  are 
often  observed. 

Symptoms.  These  may  be  obscure  in  the  mild  type  of  the  infection;  in 
medium  grades  of  the  disease  the  anaemia  is  more  or  less  marked  and  in  the 
extreme  instances  the  affection  is  characterized  by  extreme  anaemia  and  oedema. 
The  period  of  incubation  (the  stage  of  the  disease  before  the  ova  appear  in 
the  stools)  is  from  four  to  ten  weeks  and  may  be  characterized  by  irritation 
of  the  gastro-intestinal  tract.  In  some  regions  where  uncinariasis  is  common 
the  faeces  of  a  considerable  proportion  of  the  comparatively  healthy  children 
contain  ova. 

In  the  advanced  stages  of  the  infection  there  is  more  or  less  lack  of  bodily 
development;  the  skin  is  waxy  white  or  yellowish;  hair  is  present  upon  the 
scalp  but  is  not  abundant  upon  other  parts;  the  breasts  and  external  genitals 
are  poorly  developed;  the  facies  is  anxious  and  sometimes  oedematous;  the 
conjunctivae  are  pale  and  lachrymal  secretion  is  often  diminished;  the  mucous 
membranes  are  of  poor  color  and  the  tongue  may  be  marked  with  purple 
or  brownish  spots.  The  cardiac  apex  beat  is  often  visible  and  there  may  be 
cervical  pulsation;  the  abdomen  is  prominent  as  a  result  of  hepatic  and  splenic 
enlargement  and  the  presence  of  ascites.  The  extremities  may  be  oedematous 
and  sluggish  ulcers  may  be  present.  There  is  no  characteristic  febrile  move- 
ment, in  fact,  the  temperature  may  be  subnormal.  Dyspnoea  is  not  rare, 
there  may  be  palpitation  and  haemic  miurmurs  are  frequently  audible.  The 
appetite  may  be  either  diminished  or  increased  and  there  is  often  a  desire  for 
unusual  foods  such  as  salt,  pickles,  coffee,  sand  or  clay.  Either  constipation 
or  diarrhoea  may  be  noted.  Such  nervous  manifestations  as  headache,  vertigo, 
mental  hebetude  and  stupidity  are  common.     There  is  emaciation  with  marked 


ANCHYLOSTOMIASIS.  879 

muscular  weakness.  The  urine  often  contains  albumin;  casts  are  rarely 
found. 

The  blood  shows  a  varying  degree  of  anaemia,  both  the  haemoglobin  and  the 
number  of  red  corpuscles  being  diminished.  The  leucocytes  may  be  slightly 
increased  or  diminished.  An  important  characteristic  is  the  presence  of 
eosinophile  leucocytes.  These  are  said  to  be  found  in  over  90  percent, 
of  the  cases. 

The  diagnosis  is  easily  made  by  finding  the  ova  in  the  faeces;  if  the  micro- 
scope is  not  available  a  very  simple  and  accurate  test  may  be  performed  as 
follows:  Place  an  ounce  (30.0)  of  fresh  faeces  upon  a  piece  of  white  blotting 
paper  and  allow  it  to  stand  for  twenty  to  sixty  minutes;  remove  the  faeces 
and  examine  the  color  of  the  stained  paper.  In  80  percent,  of  the  cases  of 
uncinariasis  of  medium  or  severe  grade  the  stain  is  reddish-brown  and  sug- 
gestive of  blood.  In  making  this  test  the  presence  of  haemorrhoids  should 
be  excluded.    The  occvirrence  of  eosinophilia  is  an  important  diagnostic  sign. 

The  prognosis  is  favorable  save  in  advanced  instances  of  the  disease.  With- 
out proper  treatment  the  duration  of  a  single  infection  has  been,  in  one 
case,  followed  for  six  years  and  seven  months  (Stiles);  how  much  longer 
it  may  last  has  not  been  shown.  If  the  patient  is  subjected  to  re-infection  the 
disease  may  continue  for  fifteen  years  or  even  longer.  Fatalities  are  not  very 
rare  in  severe  and  prolonged  infections  which  have  not  received  proper  treat- 
ment. 

Treatment.  Uncinariasis  may  be  prevented  to  some  extent  by  disinfection 
of  faeces,  by  thorough  washing  of  the  hands,  after  having  to  do  with  earth  or 
water  which  may  contain  the  uncinaria,  and  by  boiling  all  drinking  water. 

The  most  efficient  anthelmintic  in  uncinariasis  is  thymol;  this  drug  is  best 
administered  as  follows:  After  having  placed  the  patient  upon  fluids  (milk 
and  soup)  for  three  days,  30  grains  (2.0)  of  thymol  are  given  at  8  A.  M.;  at 
10  A.  M.  the  dose  is  repeated  and  two  hours  later  a  purge  is  given,  preferably  a 
saline;  castor  oil  dissolves  thymol  and  the  solution  of  this  agent  within  the 
body  may  cause  toxic  effects;  for  the  same  reason  alcohol  should  not  be  given 
with  the  thymol  as  has  been  recommended.  After  a  week  the  stools  should 
be  examined  and  if  ova  are  still  present  the  treatment  should  be  repeated 
until  they  disappear  but  it  is  better  not  to  administer  thymol  oftener  than 
once  a  week.  It  is  very  important  to  be  certain  that  no  eggs  are  to  be 
found  in  the  faeces  before  discharging  the  patient  as  ciired. 

Thymol  carbonate  has  been  suggested  as  a  substitute  for  thymol  but  probably 
offers  no  advantages  over  the  former  drug;  male  fern  is  also  advocated. 

The  treatment  of  the  anaemia  is  that  of  secondary  anaemia  from  other 
causes  (q.  v.),  iron  and  plenty  of  nourishing  food  in  connection  with  other 
tonics  being  indicated.  It  is  considered  best  to  omit  the  iron  upon  the  days 
when  thymol  is  given   (Stiles). 


88o  PARASITIC   DISliASES. 

TRICHINIASIS. 

Synonym.    Trichinosis. 

Trichinosis,  the  term  applied  to  infection  with  the  trichina  spiralis  is 
acquired  by  eating  the  meat  of  infected  hogs.  The  parasite  is  cylindrical  in 
shape,  the  length  of  the  male  being  about  y^  of  an  inch  (from  1.4  to  1.6  mm.) ; 
the  anterior  extremity  tapers  to  a  point  while  the  posterior  extremity  is  thick- 
ened and  bifid,  each  lateral  appendage  being  somewhat  conical.  The  length 
of  the  female  is  about  three  times  that  of  the  male  and  the  tail  is  rounded. 
The  larvae  when  born  are  from  90  to  100  fx  in  length,  blunt  anteriorly  and 
pointed  at  the  caudal  extremity.  Muscle  trichinae,  the  encysted  larvae,  are 
about  I  mm.  long  and  0.04  mm.  in  thickness,  tapering  anteriorly  but  obtuse 
posteriorly;  they  lie  coiled  in  an  ovoid  capsule  which  is  at  first  transparent 
but  becomes  opaque  as  a  result  of  calcareous  infiltration. 

In  the  adult  sexual  stage  the  trichina  spiralis  inhabits  the  intestine  of  man 
and  other  animals,  such  as  the  hog,  rat,  mouse,  guinea  pig,  rabbit,  cow,  sheep, 
horse,  dog,  cat,  etc.  The  parasite  is  also  found  in  the  hen,  duck  and  pigeon. 
In  the  intestine  of  its  host  the  trichina  gives  origin  to  a  great  number  of 
larvag,  after  which  the  adults  perish  and  the  larvae  migrate  to  the  inter-mus- 
cular tissues  and  finally  into  the  substance  of  the  muscles  where  they  develop  in 
about  fourteen  days  into  the  mature  muscle  form,  setting  up,  during  the  process, 
an  interstitial  myositis  and  ultimately  becoming  encysted  in  an  oval  capsule 
which  may  contain  from  one  to  four  of  the  coiled  larvae.  The  cyst  wall  is 
transparent  at  first  and  about  0.4  mm.  by  0.25  mm.;  the  capsule  gradually 
thickens  and  becomes  infiltrated  with  calcium  salts,  this  process  taking  place 
in  from  five  to  eight  months  and  sometimes  involving  the  larva  itself.  The 
encysted  larvag  may  live  within  the  muscle  of  the  hog  for  eleven  years  and  in 
that  of  man  for  as  long  as  forty  years. 

The  human  being  usually  acquires  trichiniasis  by  eating  infected  pork 
which  has  been  cooked  insufficiently  to  destroy  the  parasite.  In  the  intestine 
the  capsules  of  the  encysted  larvae  are  dissolved  by  the  digestive  secretions 
and  their  contents  is  set  free.  In  the  intestine  they  develop  into  the  adult 
worm  in  about  three  days.  After  fertilization  has  taken  place  the  males 
perish  while  the  females,  adhering  to  the  intestinal  mucosa  or  penetrating  the 
wall  of  the  gut,  migrate  to  the  mesentery  or  the  lymph  glands  of  this  structure. 
Each  female  is  capable  of  giving  birth  to  a  great  number  of  larvae  which  leave 
the  intestinal  tract  in  the  lymph  current  and  find  their  way  to  the  muscles 
either  in  the  blood  stream  or  by  direct  migration. 

Trichiniasis  is  most  common  in  Germany  where  the  use  of  raw  or  imper- 
fectly cooked  pork  in  the  form  of  sausage  is  frequent.  Pickling  or  smoking 
infected  meat  is  not  effective  in  destroying  the  parasite  but  thorough  cooking 
will  accomplish  this  object.     In  the  United  States  the  disease  is  somewhat 


TRICHINIASIS.  88 1 

rare,  Stiles,  who  has  made  a  special  study  of  the  subject,  stating  that  up  to 
1898  not  more  than  900  instances  have  been  reported.  It  is  probable  that  many 
instances  of  the  affection  are  undetected  for  many  of  the  reported  instances  were 
unsuspected,  the  parasite  being  revealed  after  autopsy,  death  having  occurred 
f r  om  other  causes. 

Pathology.  The  morbid  changes  are  chiefly  in  the  striated  muscle  fibre 
and  consist  of  a  localized  myositis  characterized  by  granular  degeneration 
and  nuclear  proliferation.  The  cysts  are  present  in  the  muscles,  appearing 
to  the  naked  eye  as  small  grayish  oat-shaped  bodies  placed  longitudinally  in 
the  muscular  fibres,  and  the  adult  parasites  may  be  found  in  the  intestine. 
Enlargement  of  the  mesenteric  glands  and  fatty  degeneration  of  the  liver 
have  been  observed.  Important  blood  changes  occur  and  will  be  considered 
later. 

'Symptoms.  The  presence  of  trichinae  in  the  intestinal  tract  may  not  be 
followed  by  the  disease,  for  the  parasites  may  be  passed  ofi  by  the  bowel 
before  they  have  had  time  to  mature  and  reproduce  themselves;  also  the 
migration  of  only  a  few  larvee  may  not  be  characterized  by  noticeable 
symptoms. 

Following  the  ingestion  of  numerous  trichina  larvae  symptoms  of  gastro- 
intestinal irritation  may  appear  within  three  or  four  days;  there  may  be  nausea, 
vomiting,  abdominal  distress  and  diarrhoea;  general  malaise  with  prostra- 
tion and  pains  in  the  bones  and  muscles  may  occur.  These  prodromal  mani- 
festations may  be  wholly  absent  or,  on  the  other  hand,  so  severe  as  to  be  mis- 
taken for  cholera  morbus.  The  invasion  of  the  disease  takes  place  in  from 
a  week  to  ten  or  even  fourteen  days;  it  is  usually  characterized  by  a  rise  in 
temperature  to  103°  to  104°  F.  (39.6°  to  40°  C);  the  temperature  curve  is  of 
remittent  or  intermittent  type  and  is  seldom  associated  with  chills.  In  mild 
types  of  the  infection  there  may  be  no  fever.  The  migration  of  a  large  number 
of  larvae  in  the  muscular  tissue,  as  stated  above,  causes  a  myositis  which  is 
evidenced  by  muscular  pain,  increased  upon  pressure  and  active  and  passive 
movement,  and  swelling,  with  cutaneous  oedema,  appearing  first  in  the  eyelids 
and  later  in  the  extremities  and  trunk.  This  symptom  may  last  several 
days  and  disappear,  to  recur  after  a  week  or  less.  The  involvement  of  the 
muscles  of  the  jaws,  throat  and  larynx  may  result  in  painful  and  difficult 
mastication,  deglutition  and  phonation,  while  the  myositis  of  the  diaphragm, 
thorax  and  abdomen  is  accompanied  by  dyspnoea  and  painful  respiration. 
Sweating  and  cutaneous  pruritus  are  not  uncommon  and  urticarial  and  other 
eruptions  have  been  observed.  Nervous  symptoms,  such  as  headache,  sleep- 
lessness, pupillary  dilatation  and  transient  loss  of  the  tendon  reflexes,  some- 
times occur.  In  prolonged  instances  of  the  disease  emaciation  and  anasmia 
are  noted.  Increased  urine  and  albuminuria  have  been  common  in  certain 
epidemics. 
56 


882  PARASITIC    DISEASES. 

The  patient,  in  instances  of  very  severe  infection,  may  fall  into  the  typhoid 
state,  with  its  typical  manifestations. 

The  blood  usually  exhibits  a  varying  degree  of  leucocytosis  and,  what  is 
much  more  important  and  characteristic,  a  marked  eosinophilia,  the  number 
of  eosinophiles  being  in  direct  proportion  to  the  severity  of  the  infection. 

The  diagnosis  of  sporadic  instances  presents  certain  diflQculties  on  account 
of  the  resemblance  of  the  disease  to  enteric  fever  and  muscular  rheumatism, 
but  if  a  number  of  patients  are  stricken  at  once  with  characteristic  symptoms, 
particularly  after  possible  exposure  such  as  an  occasion  where  many  persons 
have  partaken  of  ham  or  sausage,  suspicion  should  at  once  be  excited.  Differ- 
ential blood  counts  should  be  made  immediately  and  the  intestinal  mucus, 
a  mild  laxative  having  previously  been  given,  should  be  examined  for  the 
parasites  which  may  be  seen  with  a  low  power  lens  as  small,  glistening,  thread- 
like bodies.  The  dyspnoea,  muscular  pains,  tenderness  and  swelling,  and  the 
oedema  are  important  diagnostic  signs.  If  the  diagnosis  is  doubtful  bits 
of  muscle  should  be  removed  from  the  deltoid  or  pectoralis  major,  under 
cocaine  or  other  local  anaesthesia,  and  examined  microscopically.  A  special 
instrument  has  been  designed  for  the  excision  of  the  muscular  tissue. 

The  prognosis  depends  upon  the  number  of  larvae  which  have  been  eaten 
and  upon  the  number  of  adult  parasites  which  develop  in  the  intestinal  tract. 
In  the  milder  infections  recovery  is  usual  within  two  weeks;  marked  gastro- 
intestinal irritation  is  considered  to  augur  well  for  the  patient.  In  severe 
instances  of  the  disease  the  illness  may  be  protracted  for  two  months  or  more 
and  is  followed  by  a  very  slow  convalescence.  The  death  rate  varies  in  differ- 
ent epidemics  from  i  to  25  or  more  percent.;  the  fatal  issue  may  occur  as 
late  as  the  sixth  week. 

Treatment.  The  prevention  of  trichiniasis  consists  in  the  inspection  of 
the  carcasses  of  all  hogs  slaughtered  for  food  and  in  the  destruction  of  those 
found  infected.  The  importance  of  clean  surroundings  for  their  stock  should 
be  explained  to  those  who  raise  swine  for  market  and  also  the  necessity  of 
proper  feeding.  While  it  is  not  certainly  knowm  how  hogs  become  infected 
it  has  been  suggested  that  the  infection  may  be  transmitted  from  the  rats 
which  thrive  about  abattoirs,  consequently  the  destruction  of  these  animals 
in  slaughter-houses  and  about  pig  styes  is  advisable.  Finally,  complete 
prophylaxis  may  be  achieved  by  the  thorough  cooking  of  all  ham  and  sausage. 

If  the  patient  is  seen  early  in  the  disease,  free  evacuations  of  the  intestinal 
contents  should  be  secured  by  means  of  large  doses  of  calomel  (followed  by  a 
saline),  rhubarb,  senna,  aloin  or  other  purgative,  with  the  object  of  freeing 
the  bowel  from  the  parasites  there  present.  With  the  purges^  anthelmintic 
drugs,  such  as  santonin,  male  fern  or  thymol,  should  be  given.  It  is  important 
that  the  bowels  should  be  kept  freely  open  for  at  least  a  week  after  infection 
has  taken  place.     Glycerin  in  doses  of  a  half  ounce  (15.0)  every  hour  has  been 


FILARIASIS.  883 

recommended.  We  know  of  no  means  to  destroy  the  larvae  within  the  mus- 
cles, but  the  use  of  picric  acid  in  doses  of  from  5  to  8  grains  (0.33  to  0.5) 
has  been  suggested. 

The  treatment  otherwise  consists  in  the  employment  of  measures  calculated 
to  relieve  the  symptoms.  The  muscular  pains  may  be  relieved  by  means  of 
hot  baths  or  applications  of  anodyne  liniments,  equal  parts  of  hydrated  chloral, 
camphor  and  menthol,  for  instance,  with  hypodermatic  injections  of  morphine 
should  these  become  necessary.  The  restlessness  and  sleeplessness  may  be 
controlled  by  the  bromides,  sulphonmethane  (sulphonal),  sulphonethylmethane 
(trional)  and  similar  drugs.  During  the  febrile  stage  the  diet  should  consist 
of  nourishing  fluids  and,  upon  the  establishment  of  convalescence,  tonics,  such 
as  strychnine,  quinine  and  iron,  with  massage  and  electricity  to  combat  the 
excessive  muscular  weakness,  are  indicated. 

FILARIASIS. 

A  number  of  different  filariae  claim  man  as  their  host.  Of  these  the  most 
common  are  the  three  species  which  are  included  under  the  term  filariiz 
sanguinis  hominis. 

1.  Filaria  Bancrojti,  the  most  frequently  found  blood  filaria,  occurs  in  most 
tropical  regions.  It  has  been  observed  in  East  India,  China,  Japan,  the 
Malay  Archipelago,  the  South  Sea  Islands,  Australia,  Africa,  and  the  West 
Indies,  as  well  as  in  the  Southern  United  States.  The  male  parasite  is  about 
i\  inches  (4  cm.)  in  length  and  -j^q"  <^f  ^^  i^^ch  (o.i  mm.)  in  thickness;  the 
anterior  extremity  is  slightly  clubbed,  the  posterior  extremity  tapering  and 
spirally  twisted.  The  female  is  brownish,  about  twice  the  length  and  thickness 
of  the  male  and  possesses  rounded  extremities;  the  ova  are  38  /x  by  14  //. 
The  embryos  measure  from  270  to  340  [i  in  length  by  7  to  11  /i  in  breadth; 
their  especial  peculiarity  is  that  they  are  found  in  the  blood  at  night  only, 
except  in  the  case  of  individuals  who  sleep  during  the  day,  when  they  are 
present  in  the  circulation  during  the  hours  which  the  host  spends  in  sleep. 

2.  Filaria  diurna  is  found  in  the  blood  during  the  waking  hours  only  and 
is  to  be  differentiated  from  /.  Bancrojti  by  this  fact  and  the  absence  of  granules 
in  the  axis  of  the  larva.  Manson  who  first  described  this  form  of  filaria 
suggests  that  it  is  the  larval  form  of  filaria  loa. 

3.  Filaria  perstans  is  also  known  only  in  its  larval  form  and  is  found  at  all 
times,  day  or  night.  The  embryos  are  smaller  than  those  of  the  preceding 
varieties,  being  about  200  /i  in  length.  They  are  actively  motile  and  have  an 
abruptly  rounded  and  truncated  posterior  extremity;  the  anterior  extremity 
is  retractile  and  possesses  a  prominent  spicule.  This  parasite  is  possibly  the 
cause  of  craw-craw,  an  ulcerative  skin  eruption  which  occurs  in  west  Africa. 


884  PARASITIC    DISEASES. 

F.  Bancrojti  is  the  most  important  of  the  above  described  parasites  and  to 
its  presence  in  the  human  body  hcematochyluria  and  elephantiasis  or  lymph 
scrotum  are  attributed. 

The  embryo  filarial  enter  the  blood  stream  by  means  of  the  lymphatics 
and.  being  no  larger  in  diameter  than  the  thickness  of  a  red  blood  cell,  are 
easily  passed  through  the  finest  capillaries;  although  enclosed  in  their  sheaths, 
they  are  actively  motile  and  may  be  easily  seen  in  specimens  of  fresh  blood. 
During  the  day  they  are  not  found  in  the  blood  except  in  very  exceptional 
instances  or  when  the  patient  is  accustomed  to  sleep  in  the  daytime  and  work 
at  night.     At  night  they  are  present  in  the  blood  stream  in  great  numbers. 

The  life-history  of  the  parasites  is  not  very  definitely  known  but  it  is  supposed 
that  they  are  withdrawn  from  the  circulation  by  the  mosquito.  The  larvae 
develop  to  some  extent  in  the  stomach  of  the  insect  and  then  migrate,  finding 
their  way  into  the  thoracic  muscles.  Upon  the  death  of  the  mosquito  the 
larvae  are  set  free  in  the  water  in  which  the  insect  has  died,  this  is  drunk  by 
human  beings,  according  to  the  older  theory,  and  the  larvae  entering  the  diges- 
tive tract,  bore  through  its  walls  into  the  lymphatic  vessels.  The  larvae  have 
been  found  in  the  proboscis  of  the  mosquito  and  the  more  probable  method 
of  transmission  is  by  means  of  the  bite  of  this  insect  and  consequent  direct 
infection. 

Symptoms.  Large  numbers  of  filariae  may  be  present  in  the  blood  with- 
out giving  rise  to  suggestive  manifestations  or  prejudicing  the  health  of  the 
host;  on  the  other  hand  certain  pathological  effects  may  be  produced. 

Hcematochyluria.  If  the  parasites  cause  stoppage  and  obstruction  of  the 
lymph  circulation  a  lymph  fistula  may  open  into  the  ureter  or  bladder 
and  the  urine  becomes  milky  {chyhiria)  from  the  admixture  of  chyle  and  if, 
as  a  result  of  the  development  of  this  fistulous  opening,  there  is  a  rupture  of 
blood-vessels,  blood  also  appears  in  the  urine  {hcematochyluria).  Without 
other  symptoms  or  marked  disturbance  of  health,  the  patient  passes  at  intervals 
opaque  milky  urine  which  may  show  an  admixture  of  blood.  The  urine  is 
otherwise  normal  in  its  constituents  but  at  times  may  be  increased  in  amount. 
In  the  intervals  of  the  chyluria  the  urine  is  of  ordinary  character.  The 
passage  of  the  chylous  and  bloody  urine  may  be  associated  with  lumbar  pain. 
Under  the  microscope  the  milky  urine  is  seen  to  contain  fat  globules,  red  blood 
cells,  and  sometimes  motile  filariae. 

Lymph  Scrotum,  Lymph  Vulva  and  certain  types  of  elephantiasis  may  result 
from  the  presence  of  the  filariae.  The  affected  parts  are  swollen  and  thickened 
and  contain  plainly  visible  and  distended  lymph  vessels;  these  are  found  to 
contain  a  milky,  turbid  or  blood-stained  fluid  which  coagulates  on  standing. 
Filariae  are  sometimes  present  in  the  fluid.  The  inguinal  and  femoral  glands 
may  be  swollen  and  soft.  Erysipelas  infection  of  the  affected  tissues  may 
occur  and  may  be  accompanied  by  chills,  fever  and  sweating. 


DRACONTIASIS.  885 

In  connection  with  the  conditions  described  above,  blood  changes,  such  as 
anaemia  and  eosinophilia,  splenic  enlargement  and  interference  with  general 
nutrition,  have  been  observed. 

Treatment.  The  prevention  of  filariasis  is,  to  some  degree,  possible  by 
boiling  the  water  used  for  drinking  and  in  the  preparation  of  food,  by  de- 
stroying mosquitoes  and  by  preventing  the  access  of  these  insects  to  human 
beings  by  means  of  bed  screens,  etc. 

There  is  no  certain  method  of  destroying  the  filariae  in  the  body  although 
good  results  have  followed  the  administration  of  thymol  in  doses  of  i  to 
5  grains  (0.065  to  0.33)  given  for  a  period  of  several  weeks;  benzoic  acid, 
sodium  benzoate  and  methylthionine  hydrochloride  (methylene  blue)  in  4 
grain  (0.25)  doses  have  been  recommended  by  certain  observers.  Chyluria 
necessitates  temporary  confinement  to  bed,  an  avoidance  of  fluids  and  fats, 
and  the  administration  of  saline  purges  to  lessen  the  tension  in  the  lymphatic 
system.  Such  treatment  may  result  in  the  temporary  disappearance  of  the 
chyle  from  the  urine.  If  fats  are  omitted  from  the  diet  the  urine  may  continue 
normal  but  the  administration  of  a  glass  of  milk  is  often  followed  by  a  recur- 
rence of  the  turbid  urine,  proving  that  the  lymphoid  fistula  is  still  patent. 

The  surgical  removal  of  the  adult  parasites  from  the  inguinal  or  other 
accessible  glands  is  often  of  pronounced  benefit  and  is  unattended  with  danger. 

DRACONTIASIS. 

Synonym.     Guinea-worm  Disease. 

Filaria  or  dranunculus  medinensis  {The  Guinea-worm)  is  a  common 
parasite  in  the  tropical  and  subtropical  parts  of  Asia,  Africa  and  America. 
The  female  only  has  been  observed;  it  is  whitish  or  yellowish  in  color,  from 
20  to  28  inches  (50  to  80  cm.)  in  length  and  from  |  to  ^  an  inch  (0.5  to  1.7  cm.) 
in  thickness.  Its  anterior  extremity  is  rounded  and  is  supplied  with  a  two- 
lipped  oral  orifice.  The  tail  tapers  to  a  blunt  point  bent  into  the  form  of  a 
hook.  The  male  is  believed  to  be  much  smaller.  The  larvae  are  supposed 
to  enter  the  alimentary  tract  of  the  host  in  drinking  water,  being  enclosed 
in  the  bodies  of  certain  small  arthropods  (cyclops)  or  free,  having  gone  through 
several  stages  of  development  inside  this  latter  organism.  The  theory  that 
the  parasites  may  enter  the  body  by  penetrating  the  skin  has  also  been  sug- 
gested. Probably  the  male  and  female  are  ingested  but  the  former  dies  after 
having  performed  the  function  of  impregnation,  while  the  female,  containing 
a  very  large  number  of  embryos,  penetrates  the  intestinal  wall,  and  migrating 
to  the  subcutaneous  tissues,  still  further  develops.  It  may  remain  quiescent 
and  is  palpable  under  the  skin;  later  the  parasite  finds  its  way  downward 
through  the  tissues  to  the  ankle  or  foot.     This  migration  is  probably  in  re- 


886  PARASITIC    DISEASES. 

sponse  to  a  desire  to  allow  the  embryos  to  escape.  When  the  sought  for 
situation  has  been  reached  the  head  is  thrust  through  the  skin,  caus- 
ing a  small  vesicle  which  is  surrounded  by  a  more  or  less  inflamed  area. 
The  vesicle  ultimately  bursts,  leaving  an  ulceration,  at  the  base  of  which  the 
head  of  the  parasite  may  be  demonstrated.  Having  discharged  the  embryos 
the  parasite  leaves  the  body.  Usually  there  is  but  a  single  worm  in  one  host, 
although  this  is  not  always  the  case. 

Symptoms.  These  are  those  of  a  localized  inflammation  at  the  site  of  exit 
of  the  parasite;  there  may  be  a  slight  febrile  movement  but  this  is  only  tran- 
sient if  cleanliness  is  observed  after  removal  of  the  parasite.  If  the  worm 
is  torn  diiring  its  removal,  suppuration  with  the  usually  associated  symp- 
toms is  said  to  be  a  very  probable  result. 

Treatment.  Prevention  consists  in  the  thorough  filtering  and  boiling  of 
drinking  water  and  in  avoiding  contact  with  muddy  water  in  which  the  cyclops 
may  be  present. 

The  natives  of  the  countries  where  the  guinea-worm  is  common  as  a  rule 
moisten  the  ulcerated  bases  of  the  ruptured  vesicles  and,  when  the  head  of 
the  parasite  is  extruded,  it  is  fastened  round  a  bit  of  wood  which  is  gradually 
twisted  until  after  several  days,  the  entire  worm  is  withdrawn.  Injection 
of  mercury  bichloride  solution  (i  to  looo)  into  the  head  will  kill  the  parasite 
after  which  it  may  be  readily  pulled  out.  Injections  of  mercury  into  the 
tissue  adjacent  to  the  worm  also  kill  it  and  it  may  be  removed  by  excision. 
The  wound  should  be  dressed  antiseptically;  in  this  connection  i  to  15 
phenol  solution  is  recommended  but  should  be  carefully  watched  lest  it 
cause  gangrene  of  the  part.  The  local  application  of  the  leaves  of  the  "  arma- 
pattee"  plant  is  recommended  by  native  physicians  in  India  and  large  doses 
of  asafoetida  are  said  to  be  fatal  to  the  parasite. 

Other  filariae  have  been  found  in  man  but  much  less  frequently  than 
those  previously  described.  Of  these  the  following  are  worthy  of  brief 
mention. 

Filaria  loa  occurs  in  West  Africa  and  exists  in  the  subcutaneous  tissues, 
especially  those  of  the  face,  where  it  wanders  about  causing  burning  and  itching. 
It  is  particularly  frequent  beneath  the  conjunctiva  where  it  induces  swelling 
and  inflammation.  This  parasite  has  been  found  in  the  Western  Hemisphere 
whither  it  has  probably  been  brought  by  African  slaves. 

Filaria  immitis.  This  is  a  common  parasite  in  the  dog  and  has  been  found 
in  the  portal  vein  of  man,  the  eggs  being  present  in  the  walls  of  the  ureters 
and  bladder. 

Filaria  Bentis  has  been  observed  in  a  cataract.  Filaria  trachealis  and 
bronchialis  has  been  observed  in  the  trachea,  bronchi  and  lungs.  Filaria 
labialis  has  been  demonstrated  in  labial  pustifle  and  Filaria  hominis  oris 
has  been  found  in  the  mouth. 


INTESTINAL    CESTODES    T.ENLE    OR    TAPE-WOR^'.IS.  887 

TRYPANOSOMIASIS. 

Trypanosoma  hominis,  the  organism  which  is  beUeved  to  be  the  cause  of 
African  sleeping-sickness,  has  been  discussed  in  the  section  upon  infectious 
diseases. 

CESTODES. 

ECHINOCOCCUS  DISEASE. 

Synonym.    Hydatid  Disease. 

The  taenia  echinococcus  has  been  described  in  the  section  upon  diseases 
of  the  Hver.  Echinococcus  diseases  of  the  lungs,  spleen  and  other  organs 
have  been  discussed  in  the  sections  devoted  to  the  affections  of  the  organs  in 
question  and  to  these  the  reader  is  referred. 

INTESTINAL  CESTODES,  T^mJE  OR  TAPE- WORMS. 

Various  types  of  taenia  are  found  in  the  human  intestine  as  a  result  of  the 
ingestion  of  the  undeveloped  larvae  which  occur  in  the  muscular  tissue  or 
other  organs  of  animals.  The  ova  of  the  tape-worm  pass  from  the  intestine 
of  the  host  in  the  dejections  and  are  taken  into  the  bodies  of  various  animals 
where  they  become  fixed  in  the  muscles  or  other  tissues,  probably  being  trans- 
ferred thither  by  the  blood  or  lymph  currents.  Within  a  few  months  after 
lodgment  the  ova  develop  into  cysticerci  or  bladder-worms;  these  present  the 
following  characteristics.  The  cysticercus  is  inclosed  in  a  thin  connective 
tissue  wall  within  which  lies  the  bladder-worm,  which  really  is  the  head  of 
the  future  tape-worm  and  is  termed  the  scolex.  Behind  the  head  there  is  a 
constricted  neck  consisting  of  undeveloped  segments,  the  terminal  one  being 
distended  into  a  bladder -like  body.  In  some  forms  of  taenia  the  ova  may 
become  encysted  in  the  intestinal  wall  of  the  original  host  and  subsequent 
development  of  the  full-grown  parasite  in  the  intestine  results  in  an  auto- 
infection;  more  commonly,  however,  there  is  an  intermediate  host  in  the 
tissues  of  which  the  larvae  develop  and  are  finally  eaten  by  a  third  host  to 
whose  intestinal  wall  the  parasite,  its  cyst  wall  being  removed  by  the  action 
of  the  digestive  fluids,  becomes  attached  and  gives  origin  to  segment  after 
segment,  thus  forming  a  new  taenia. 

Taenia  mediocanellata,  tcBnia  saginata  or  beef  tape-worm  is  the  most 
common  variety  of  tape- worm  in  this  country;  it  is  also  frequently  found  in 
other  parts  of  the  world,  especially  where  beef  is  largely  consumed.  Its 
usual  length  is  from  3  to  8  yards  (3  to  8  meters);  its  head  is  four-sided 
and  pear-shaped  and  possesses  no  booklets  or  rostellum,   but  in  place  of 


OOO  PARASITIC    DISEASES. 

these  is  provided  with  four  cup-shaped  sucking-discs  placed  at  its  corners. 
The  head  is  about  y\  of  an  inch  (2  mm.)  in  diameter;  the  neck  is  slender 
and  prolonged;  the  first  segments  are  short,  their  transverse  diameter  exceeding 
their  length.  The  segments  gradually  increase  in  length  and  near  the  pos- 
terior extremity  of  the  parasite  are  about  §  of  an  inch  (16  to  18  mm.)  long  and 
about  one-half  as  broad.  The  genital  pores  in  adjacent  segments  irregularly 
alternate  upon  the  opposite  margins  and  are  placed  slightly  posterior  to  the 
middle  of  the  margin  of  each.  The  embryophores  are  slightly  ovoid,  brownish 
in  color  and  measure  30  to  40  /x  by  20  to  30  [i.  The  shell  is  thick  and  radially 
striated.  The  uterus  is  situated  in  the  middle  of  each  proglottis  and  consists 
of  a  median  stem  with  eighteen  to  thirty  lateral  branches.  The  ripe  seg- 
ments are  passed  in  the  stools  and  are  eaten  by  cattle,  in  the  muscles  of 
which  the  cysticerci  develop.  The  cysticercus  of  taenia  mediocanellata  has 
never  been  found  in  human  muscle. 

Taenia  solium  {the  pork  tape-worm)  is  more  common  in  Europe  than 
in  America  and  is  taken  into  the  human  intestine  with  raw  or  insufl&ciently 
cooked  "measly"  pork.  But  one  worm  is  usually  present  in  a  single  host 
though  multiple  infections  have  been  observed.  Taenia  solium  is  about  6  to  12 
feet  (2  to  4  meters)  in  length.  Its  head  is  more  spherical  than  that  of  taenia 
mediocanellata  and  somewhat  tetragonal  in  shape  due  to  the  presence  of  four 
cup-like  thick-lipped  suckers;  the  head  is  supplied  with  a  thick  rostellum  bear- 
ding a  double  row  of  booklets,  about  twenty-eight  in  number.  The  head  is  about 
the  size  of  that  of  a  pin;  it  is  provided  with  a  rather  slender  neck  about  \  of 
an  inch  (i  cm.)  long  and  is  succeeded  by  the  segments  or  proglottides  which, 
when  mature,  measure  about  \  of  an  inch  (i.o  to  1.2  cm.)  in  length  and  about 
\  of  an  inch  (6  to  8  mm.)  in  width.  The  segments  are  bisexual,  the  uterus 
being  situated  in  the  middle  of  each  and  appearing  as  a  median  stem  with  from 
seven  to  ten  coarsely  dendritic  branches  on  either  side.  The  male  organs 
are  small  vesicular  bodies  placed  in  the  anterior  part  of  each  proglottis.  There 
are  thousands  of  embryophores  in  each  segment,  the  former  being  nearly 
spherical,  light  brown  in  color  and  measuring  about  35  //  in  diameter.  The 
shell  is  thick  and  radially  striated.  The  taenia  solium  reaches  maturity  and 
begins  to  give  off  ripe  segments  in  about  three  to  four  months.  The  ova 
are  taken  into  the  intestinal  tract  of  the  hog  or  of  man,  and  the  embryos  be- 
coming freed  from  the  shell  by  the  action  of  the  digestive  juices,  migrate  to 
various  parts,  the  muscles,  brain,  liver  or  eye,  and  become  cysticerci. 

Dibothriocephalus  latus,  tcBuia  lata  or  hothriocephalus  latus  (the  fish 
tape-worm)  is  found  in  the  human  intestine  and  in  that  of  the  dog  and 
cat.  This  parasite  does  not  occur  in  the  United  States  except  in  imported 
instances  but  is  common  in  Switzerland,  Italy,  Southern  Germany,  along 
the  shores  of  the  Baltic  Sea  and  in  Japan. 

The  larvae  develop  in  the  peritonaeal  and  muscular  tissues  of  certain  fresh- 


INTESTINAL    CESTODES,    T^NI.E    OR    TAPE-WORMS.  889 

water  fish  and  are  thus  taken  into  the  intestine  of  man.  Dibotliriocephalus 
latus  is  the  longest  of  the  tape-worms,  the  adult  measuring  from  10  to  30 
feet  (3  to  10  meters)  in  length;  the  head  is  elongated  and  almond-shaped, 
-jV  to  j%  inch  (2  to  5  mm.)  long  and  about  -g^  of  an  inch  (0.7  mm.)  broad; 
it  is  supplied  with  two  lateral  groove-like  suckers;  there  are  no  booklets. 
The  length  of  the  neck  varies  according  to  the  degree  of  contraction.  Tlie 
segments  number  from  3,000  to  4,000,  the  anterior  links  being  not  well  marked; 
they  increase  slightly  in  length  but  markedly  in  width,  the  mature  segments 
being  -jV  to  -jV  of  an  inch  (2  to  4  mm.)  long  and  J  to  §  of  an  inch  (i  to  2  cm.) 
wide.  The  ova  are  ellipsoidal,  68  to  70  /i  by  45  fi,  and  operculated.  Ovu- 
lation takes  place  in  the  intestine  and  the  eggs  are  discharged  from  the  uterus, 
appearing  in  the  dejections  in  large  numbers.  Further  development  takes 
place  in  water  and  the  embryo  is  presumably  swallowed  by  its  intermediate 
host. 

Dibothriocephalus  cordatus  is  similar  to  the  above  and  is  commonly  a 
parasite  of  seals.     It  has  been  observed  in  man  in  one  instance. 

Bothriocephalus  Mansoni  has  been  observed  in  the  larval  stage  only;  this 
has  been  found  in  the  subcutaneous  tissue,  in  the  pleural  cavity  and  in  the 
urine.     The  larva  is  thick,  flat  and  about  an  inch  (3  cm.)  in  length. 

Dipylidium  caninum,  tcBnia  canina,  tania  eliptica  or  tcenia  cucumerina 
is  common  in  the  dog  and  has  been  found  in  the  human  intestine,  more  especi- 
ally in  children.  The  intermediate  hosts  are  the  dog  flea  (pulex  serraticeps), 
dog  louse  (trichodectes  canis)  and  the  human  flea  {pulex  irritans).  These 
insects  get  the  ova  from  faecal  matter  adherent  to  the  hairs  about  the  anus 
of  the  dog  and  the  larvae  are  transferred  to  the  human  alimentary  tract  upon 
the  fingers,  these  having  been  used  to  crush  fleas,  or  having  been  licked 
by  dogs.  The  parasite  is  6  to  14  inches  (15  to  35  cm.)  long;  its  ova  are 
spherical  and  from  43  to  50  [J.  in  diameter. 

Hymenolopsis  nana  (tcBnia  nana)  is  most  frequently  observed  in  Italy 
and  other  parts  of  southern  Europe.  It  is  common  among  the  children  of 
the  poorer  classes;  the  parasite  inhabits  the  lower  portion  of  the  ileum  and 
as  many  as  a  thousand  may  be  present  in  a  single  individual.  Taenia  nana 
is  common  in  the  rat  and  is  conveyed  to  the  human  intestine  upon  water 
contaminated  with  the  faecal  matter  of  these  animals  or  that  of  a  human  host, 
upon  food  to  which  rats  have  had  access  or  upon  fingers  which  have  been 
soiled  by  contact  with  the  anal  tissues.  The  worm  is  from  ^  to  ^  an  inch 
(i  to  1.5  cm.)  or  more  in  length;  the  subglobular  head  is  supplied  with  four 
suckers  and  a  rostellum  surrounded  by  a  single  row  of  booklets.  The  neck 
is  slender  and  is  succeeded  by  about  150  short,  broad  segments.  The 
ova  are  oval  or  spherical,  about  40  fi  in  diameter  and  possess  a  double 
wall. 

Hymenolopsis  diminuta  or  tcsnia  jlavopunda   occurs  as  a  parasite  of 


890  PARASITIC   DISEASES. 

rats  and  mice  and  has  been  observed  in  man.  The  larvas  develop  in  beetles, 
earwigs  and  especially  in  meal  moths  in  the  larval  stage.  The  worm  is  from 
J  of  an  inch  to  2  inches  (10  to  60  mm.)  long  and  possesses  a  small  globular 
head  with  four  suckers  and  a  rostellum  without  hooklets;  the  neck  is  short 
and  is  succeeded  by  800  to  1,200  or  more  segments  which  are  short  and  broad. 
The  ova  are  rounded,  yellowish  and  double-walled,  the  external  diameter 
being  from  54  to  86  [x. 

Hymenolopsis  lanceolata  or  tania  lanceolata  is  found  as  a  parasite  of 
geese  and  ducks  in  Europe  and  has  occurred  in  the  human  subject  in  at  least 
one  instance.  The  adult  worm  measures  from  i  to  5  inches  (3  to  13  cm.) 
in  length;  the  head  is  very  small  and  is  supplied  with  a  rostellum  which  pos- 
sesses eight  hooklets  and  four  suckers.  The  neck  is  short  and  is  followed  by 
about  300  short  broad  segments.  The  ova  are  double-walled,  spherical 
and  from  60  to  100  {x  in  diameter.  The  larvas  of  this  parasite  are  believed 
to  exist  in  certain  crustaceans. 

Davainea  Madagascariensis  or  tania  Madagascariensis  has  been  found 
as  a  human  parasite  in  Madagascar,  Guiana,  Mauritius  and  Eastern  Asia. 
The  larval  form  has  not  been  observed.  The  adult  worm  is  about  an  inch 
(3  cm.)  long;  the  head  is  small  with  four  suckers  and  a  retractile  rostellum 
fitted  with  a  double  row  of  about  go  hooklets.  The  segments  number  from 
500  to  700  and  are  slightly  longer  than  broad.  The  embryo  is  from  8  to  15 
,«  long  and  is  surrounded  by  a  thin  double  wall. 

Taenia  confusa  is  a  recently  described  species  about  which  little  is  known 
but  which  may  be  a  variety  of  tasnia  solium.  The  parasite  has  been  observed 
in  one  instance  in  Nebraska. 

Taenia  Africana  and  taenia  marginata  are  rarely  observed  in  the  human 
subject. 

Tape-worms  are  found  in  patients  of  all  ages,  even  young  children  may 
be  affected. 

Symptoms.  These  are  not  definite  nor  diagnostic  in  any  way,  the  existence 
of  the  parasite  frequently  being  evidenced  by  no  suspicious  manifestations 
whatever.  In  other  instances  various  symptoms  of  local  irritation  may  be 
present  and  neurotic  individuals,  when  aware  of  their  disease,  often  complain 
of  symptoms  which  have  a  purely  imaginary  basis.  Local  manifestations 
such  as  abdominal  distress,  sensations  of  weight  and  fulness  in  the  region  of 
the  stomach,  particularly  after  eating,  capricious  appetite,  diarrhoea  alter- 
nating with  constipation,  salivation,  nausea  and  vomiting  and  emaciation 
with  anaemia  are  sometimes  observed. 

Reflex  nervous  phenomena  are  not  unusual  and  may  consist  of  irritability 
of  temper,  mental  depression,  lassitude,  insomnia,  vertigo,  itching  at  the  nose, 
ringing  in  the  ears,  visual  disturbances  and  pupillary  dilatation.  Choreic 
movements  and  epileptiform  convulsions  are' said  to  occur  in  rare  instances 


INTESTINAL    CESTODES,    T^NI^    OR    TAPE-WORMS.  89I 

but  their  causation  can  generally  be  explained  upon  other  basis  than  that 
of  the  presence  of  taeniae. 

Marked  and  even  fatal  anaemia  has  been  brought  about  by  the  presence  of 
the  dibothriocephalus  latus  and  may  be  due  to  some  toxic  substance  produced 
by  the  worm. 

The  diagnosis  can  be  certainly  made  only  by  finding  segments  of  the  para- 
site or  its  eggs  in  the  faeces  or  upon  the  underclothing  and  if  tape-worm  is- 
suspected  the  administration  of  some  simple  purge  will   unless  the  suspicion 
is  groundless,  bring  to  light  conclusive  proof. 

The  prognosis  of  tape-worm  disease  is  uniformly  favorable. 

Treatment.  Prophylaxis  consists  in  using  none  but  thoroughly  cooked 
meat  or  fish  for  food,  in  boiling  all  drinking  water,  in  destroying,  by  crema- 
tion, all  faecal  matter  which  may  contain  segments  or  ova,  for  if  these  are  not 
so  disposed  of  there  is  likelihood  that  they  may  be  ingested  by  hogs  or  cattle. 
The  institution  of  governmental  inspection  of  the  carcasses  of  animals  used 
for  food  is  most  important  in  the  prevention  of  tape-worm  disease,  although 
cold  storage  is  said  to  destroy  the  cysticerci  in  three  or  four  weeks.  It  is  an 
interesting  fact  that  the  larvae  are  found  chiefly  in  the  muscles  of  the  jaw  in 
the  case  of  the  beef  tape-worm. 

There  are  various  effectual  methods  of  ridding  the  intestine  of  tape-worms 
and  numerous  drugs  have  been  employed  with  this  object  in  view.  The 
following  formula  will  be  found  most  certain.  I^  corticisgranati,  §53(15.0); 
seminis  peponis,  oiii  (90.0);  ergotae,  5ss  (2.0);  contere  et  boulliat  semi  hora 
in  aqua,  3viii  (25o.o);  cola  et  adde  extractum  filicis  aetheris,  3i  (4.0);  oleum 
tighi,  n^^  ii  (0.13);  pulverem  acacias,  3ii  (8.0).  Misce  et  fiat  emulsio. 
Signa — Take  six  teaspoonsful  (24.0)  of  Rochelle  salt  on  retiring  and  the 
remedy  in  the  morning. 

Many  clinicians  advise  the  patient  to  subsist  upon  a  light  diet,  consisting 
of  bread,  milk  and  soups,  for  two  or  three  days  preceding  the  administration 
of  the  anthelmintic  in  order  that  the  parasite  may  be  somewhat  weakened 
and  its  hold  upon  the  intestinal  mucosa  rendered  less  firm;  the  systematic 
administration  of  mild  purges  for  a  day  or  two  before  taking  the  taeniafuge 
is  also  advised  in  order  that  the  bowel  may  be  cleared  of  faecal  matter  which 
might  otherwise  in  some  degree  protect  the  worm.  In  this  connection  it 
should  be  stated  that  castor  oil  should  not  be  given  in  connection  with  any 
preparation  of  male  fern  for  the  former  markedly  increases  the  solution  and 
absorption  of  filicic  acid  which  sometimes  causes  toxic  symptoms. 

Kousso  flowers  are  an  active  anthelmintic  but  must  be  fresh  in  order  to 
exert  their  best  effect  and  have  the  disadvantage  that  thev  are  likely  to  cause 
emesis  and  intestinal  distress.  An  infusion  of  i  ounce  (30.0)  of  the  flowers 
in  8  ounces  (250.0)  of  water,  taken  in  the  morning  and  preceded  the  night 
before  by  a  saline  cathartic,  will  usually  cause  the  death  of  the  parasite.     A 


892  PARASITIC    DISEASES. 

purge  is  seldom  necessary  after  the  administration  of  kousso  but  should  the 
parasite  not  appear  within  six  hours  after  it  has  been  taken,  a  cathartic  is  indi- 
cated. Koussin,  a  resin  obtained  from  kousso  has  been  given  with  good  results, 
the  dose  being  20  to  40  grains  (1.33  to  2.66)  in  capsules. 

Pomegranate  may  be  given  alone  as  a  taeniafuge  as  well  as  in  the  combina- 
tion suggested  above.  It  is  best  administered  in  decoction  (B.  P.,  i  to  5, 
•dose  i  to  2  ounces — 15.0  to  60.0)  and  of  this  several  doses  may  be  taken,  fasting 
at  hour  intervals.  It  should  be  preceded  by  a  brisk  cathartic  and,  if  the 
remedy  does  not  have  a  purgative  effect,  followed  by  another.  In  case  the 
patient  is  unable  to  take  the  decoction  on  account  of  its  exceeding  unpalatable 
taste  it  is  recommended  that  the  proper  quantity  should  be  evaporated  upon 
a  water  bath  to  a  pilular  consistency  and  administered  in  capsules. 

Pelletierine  tannate,  a  mixture  of  the  active  principles  of  pomegranate, 
is  one  of  the  most  reliable  taeniafuges  and  is  decidedly  preferable  to  pome- 
granate itself  on  account  of  the  facility  with  which  it  can  be  taken  and  its 
freedom  from  nauseating  properties.  It  is  usually  given  in  capsules,  pre- 
ceded and  followed  by  a  purge.  It  should  be  administered  with  great  cau- 
tion to  children.     The  dose  for  an  adult  is  4  gr.  (0.250). 

Pumpkin  seed  is  considered  less  efficient  than  the  previously  mentioned 
anthelmintics;  it  is  preferably  given  in  emulsion  which  is  prepared  by  pow- 
dering 2  ounces  (60.0)  of  the  seeds  in  a  mortar  with  8  ounces  (250.0) 
of  water  until  the  husks  are  loosened  and  an  emulsion  is  made,  the  mixture 
is  then  strained  and  the  whole  amount  taken  fasting;  some  observers  consider 
that  the  effect  is  better  if  the  husks  are  not  strained  off.  The  seeds  may  also 
be  beaten  into  a  paste  with  milk  and  sugar.  The  resin  in  doses  of  15 
grains  (i.o)  and  the  expressed  oil  in  doses  of  4  drachms  (15.0)  have  been 
used  as  substitutes  for  the  seeds  and  are  said  to  be  equally  efficient. 

Kamala  in  doses  of  i  to  2  drachms  (4.0  to  8.0)  will  kill  the  tcBtiia  solium 
and  may  be  given  mixed  with  syrup  to  which  a  little  hyoscyamus  is  added 
to  prevent  griping;  the  dead  parasite  will  often  appear  at  the  third  or  fourth 
stool  after  the  use  of  the  drug.  If  a  single  dose  is  ineffective  it  may  be  repeated 
at  three  hour  intervals  until  five  or  six  doses  have  been  taken. 

To  be  certain  that  the  entire  worm  has  been  expelled  by  any  given  mode 
of  treatment  it  is  necessary  to  find  the  head  of  the  parasite  and  this  often 
entails  a  careful  search,  for,  being  very  small,  this  part  is  easily  lost  in  the 
discharges.  Even  though  the  head  is  not  found,  in  many  instances  it  may 
have  been  passed  and  overlooked.  If  it  remains  in  the  intestine  in  three  to 
four  months  segments  will  again  appear  in  the  stools  and  treatment  may 
be  repeated.  Obstinate  instances  may  be  due  to  the  fact  that  the  head  is  hidden 
beneath  the  valvulae  conniventes  and  is  thus  protected  from  the  action  of  the 
taeniafuge. 


ARACHNID.E    AND    TICKS.  893 

PARASITIC  INSECTS. 
ARACHNIDiE  AND  TICKS. 

Sarcoptes  or  acarus  scabiei  or  the  itch  mite  is  not  uncommon  in  persons 
of  uncleanly  habits.  It  is  nearly  circular  in  shape  and  hardly  visible  to  the 
naked  eye.  The  female  burrows  in  the  epidermis  more  especially  where  the 
skin  is  thin  as  between  the  fingers,  upon  the  flexor  surfaces  of  the  knees,  in 
the  groins,  etc.  The  eggs  are  deposited  in  this  burrow  and  hatch  in  about 
one  week  and  reach  the  adult  stage  about  fourteen  days  later.  The  parasite  is 
most  frequently  observed  in  persons  of  uncleanly  habits  and  is  transferred 
by  bodily  contact   or  upon  clothing. 

Symptoms.  These  consist  of  intense  pruritus;  the  burrows  may  be  detected 
in  the  skin  of  the  affected  parts  but  are  often  obscured  by  scratch  marks. 

Treatment.  The  body  should  be  thoroughly  cleansed  with  soft  soap  and 
hot  water  for  the  purpose  of  breaking  open  the  burrows  and  exposing  the 
parasite;  next  the  surface  should  be  rinsed  with  cold  water  and  dried,  after 
which  sulphur  ointment  should  be  rubbed  carefully  into  the  skin.  The 
oflScial  ointment  in  full  strength  is  often  too  irritating  and  it  is  usually  wise 
to  dilute  it  somewhat.  The  following  application  may  also  be  employed: 
Oil  of  cade,  i  drachm  (4.0);  sulphur  ointment,  2  drachms  (8.0);  lanolin, 
5  drachms  (20.0).  After  the  inunction  the  patient  should  go  to  bed  and  the 
next  morning  should  wash  himself  clean  and  put  on  clean  clothing.  One 
such  application  is  usually  sufficient  to  eflfect  a  cure  but  it  may  be  repeated 
once  or  twice.  In  order  to  prevent  re-infection  the  bed  linen  and  the  clothing 
previously  worn  should  be  burned  dr  disinfected  by  boiling  or  exposure  to 
steam  under  pressure. 

Sarcoptes  scabiei  hominis  is  a  variety  of  the  itch  mite  which  infests  the 
cat,  dog,  cow,  horse,  and  other  animals;  it  is  sometimes  transferred  to  man 
but  dies  spontaneously, 

Leptus  autumnalis  {the  harvest  bug)  is  a  tiny  red  parasite  possessing  six 
legs,  rows  of  bristles  upon  its  dorsal  and  ventral  surfaces  and  sharp  mandib- 
les. It  is  common  in  summer  on  grass  and  other  plants  and  attaches  itself 
particularly  to  the  skin  of  the  ankles  and  legs  into  which  it  penetrates  suffi- 
ciently far  to  obtain  nourishment.     It  causes  irritation  and  pruritus. 

Treatment  consists  in  inunctions  of  sulphur,  mercury  or  naphthol  oint- 
ments or  the  employment  of  a  lotion  of  i  to  500  mercury  bichloride  solution. 

Demodex  folliculorum  {the  comedo  mite)  is  a  minute  parasite  with  a 
worm-like  body  and  short  legs.  It  is  about  -^^  of  an  inch  (0.3  to  0.4  mm.) 
in  length  and  infests  the  sebaceous  follicles  of  the  skin,  particularly  that  of 
the  face  and  nose,  from  which  it  can  often  be  expressed.  It  causes  no  special 
symptoms  but  may  incite  inflammation  of  the  follicles. 


894  PARASITIC    DISEASES. 

Treatment.  The  insect  may  be  expressed  by  means  of  a  watch  key  or  a 
comedone  extractor.  Prevention  consists  in  frequently  washing  the  face  with 
a  pure  soap  and  a  flesh  brush;  i  to  500  mercury  bichloride  solution  may 
be  employed  as  a  lotion. 

Pentastomata.  These  include  the  pentastonium  tanioides  (lingulata  rhin- 
aria)  which  inhabits  the  nasal  fossae  of  the  dog,  horse  and  rarely,  those  of 
man.  The  female  possesses  a  lancet-shaped  body  from  3  to  4  inches  (9  to  12 
cm.)  long  while  the  male  is  about  a  third  of  this  size.  The  ova,  are  ejected 
in  sneezing  and  may  be  taken  into  the  human  body.  The  larvae  have  been 
found  in  the  liver,  lungs,  and  kidneys. 

Pentastomum  constrictum  {porocephalus  constridiis)  is  a  very  rare  para- 
site about  J  an  inch  (1.5  cm.)  long  which  has  been  found  in  a  few  instances 
in  the  liver  and  lungs.  In  one  case  the  parasites  were  expectorated  in  con- 
siderable number. 

"Ixodiasis  (tick  fever)  has  been  considered  in  the  section  upon  infectious 
diseases. 

PARASITIC  FLIES. 

Myiasis.  This  term  is  applied  to  the  condition  characterized  by  the  pres- 
ence of  the  larvag  of  various  species  of  flies  (diptera).  Several  varieties  of 
flies,  notably  the  flesh  or  blue-bottle  fly  (sarcophila  carnaria),  the  common 
house  fly  {jnusca  domestica),  the  blow-fly  (calliphoria  vomitoria)  and  the 
screw-worm  fly  (compsomyia  macellaria)  deposit  their  eggs  upon  wound 
surfaces,  these  hatch  within  twenty-four  hours  and  the  lesions  become  filled 
with  maggots  or  larvae,  producing  the  condition  known  as  myiasis  vidnerum. 

The  ova  of  the  above  mentioned  flies  may  also  be  taken  into  the  alimen- 
tary tract  and  cause  intestinal  myiasis;  the  larvae  of  these  and  of  other  species 
have  been  observed  in  vomitus  and  faeces.  Usually  intestinal  myiasis  is  not 
attended  by  any  serious  results,  sometimes  ulcerations  and  fatal  inflamma- 
tions of  the  colon  result. 

Ova  are  sometimes  deposited  in  the  nostrils,  ears,  conjunctivae,  urethra 
and  vagina  but,  as  a  rule,  not  unless  disease  is  present  in  these  situations. 
Serious  consequences  may  follow  the  presence  of  larvae  in  the  ears  and  nose. 

Cutaneous  myiasis  is  usually  due  to  the  larvae  of  bot-flies  (estridas).  These 
attack  the  skin  of  the  horse,  ox,  sheep,  and  other  animals  and  have  been 
observed  in  man,  in  most  instances  in  tropical  regions.  The  parasites  bore 
beneath  the  skin  and  cause  lesions  resembling  boils;  the  parts  most  frequently 
attacked  are  the  abdomen  and  scrotum. 

Myiasis  of  the  skin,  due  to  the  presence  of  the  larvae  of  musca  vomitoria 
has  been  noted. 

In  Russia,  and  more  rarely  elsewhere,  cutaneous  infection  with  the  larva 


PEDICULOSIS.  895 

of  the  horse  bot-fly  (gastrophilus  eqid)  produces  a  migrating  eruption  con- 
sisting of  a  slightly  raised  pinkish  line  which  traverses  the  skin  with  more  or 
less  rapidity. 

An  epidemic  urticaria  is  common  in  certain  countries  as  a  result  of  the 
presence  of  different  species  of  caterpillars  especially  the  cnethocampa.  Actual 
contact  with  these  insects  is  said  not  to  be  necessary  for  the  production  of 
this  eruption. 

OTHER  PARASITIC  INSECTS. 
PEDICULOSIS. 

Synonym.     Phthiriasis, 

Three  forms  of  pediculi  are  parasitic  in  man,  the  pediculus  capitis,  the 
pediculus  corporis  and  the  pediculus  pubis. 

Pediculus  capitis  {the  head  louse)  infests  the  hair  and  scalp  of  uncleanly 
individuals.  The  male  insect  is  about  ^ry  of  an  inch  (i  mm.)  in  length  while 
the  female  is  somewhat  longer.  The  parasites  multiply  with  great  rapidity, 
the  female  laying  50  or  more  ova  or  nits.  These  are  attached  to  the  hairs, 
are  hatched  in  about  a  week  and  within  three  weeks  are  able  to  reproduce 
themselves. 

Symptoms.  These  consist  of  itching  and  irritation  of  the  scalp  and  if 
the  insect  bores  beneath  the  skin,  an  eczema  or  pustulous  dermatitis  may  be 
excited,  particularly  in  the  occipital  region,  which  results  in  the  production 
of  crusts  and  scabs  which  mat  the  hair  into  a  filthy  and  disgusting  mass 
known  as  the  plica  polomca  from  its  frequence  amongst  the  Polish  Jews. 

The  diagnosis  is  easily  made  by  observing  the  insect  itself  or  by  detecting 
the  nits,  which  are  minute  whitish  bodies  attached  to  the  hairs. 

Treatment.  To  rid  the  scalp  of  the  adult  parasites  is  an  easy  matter  but 
to  destroy  the  ova  is  quite  a  different  consideration.  The  lice  themselves 
may  be  killed  by  thoroughly  rubbing  kerosene  or  turpentine  into  the  hair. 
Staphisagria  is  a  classical  and  effective  parasiticide  and  a  combination  of  the 
fluidextract  with  acetic  acid  and  aether  (i  to  8)  is  recommended;  the  acid  will 
dissolve  the  gum  with  which  the  nits  are  stuck  to  the  hairs  and  permit  their 
removal  with  a  fine  toothed  comb.  Such  removal  is  usually  necessary,  espe- 
cially in  women  who  object  to  clipping  of  the  hair.  Staphisagria  should  not 
be  applied  if  the  scalp  is  abraded  for  poisonous  symptoms  have  been  observed 
to  follow  its  use.  Phenol  in  2  percent,  solution  and  the  tincture  of  cocculus 
indicus  may  also  be  employed.  In  using  any  of  the  remedies  suggested  it  is 
wise  to  make  the  applications  upon  several  successive  evenings,  the  patient 
sleeping  with  the  moistened  hair  WTapped  in  a  turban  made  of  a  towel  and 
taking  a  thorough  shampoo  on  rising. 

Pediculus  corporis  or  vestimentorum  {the  body  louse)  inhabits  the  seams 


896  PARASITIC    DISEASES. 

in  the  clothing  of  persons  of  filthy  habits  and  derives  its  sustenance  by  sucking 
the  blood  through  its  proboscis  which  it  inserts  through  the  skin.  These 
punctures  are  often  evidenced  by  a  minute  haemorrhagic  point  and  are  most 
abundant  upon  the  neck,  back  and  abdomen.  The  parasite  is  twice  or  three 
times  the  size  of  the  head  louse  and  is  whitish-gray  in  color.  It  deposits  its 
eggs  upon  the  underclothing,  where  they  may  be  found  after  a  prolonged 
search. 

Symptoms.  These,  as  in  the  case  of  the  head  louse,  consist  of  pruritus 
and  irritation.  Linear  scratch  marks  may  be  observed  and  in  long-standing 
instances  a  scaly  and  pigmented  condition  of  the  skin  {vagabond's  disease) 
results. 

Treatment.  The  infected  clothing  should  be  burned  or  subjected  to 
steam  or  hot-air  disinfection.  The  itching  may  be  relieved  by  warm  baths 
to  which  sodium  carbonate  or  bicarbonate  has  been  added  and  by  the  appli- 
cation of  antipruritic  lotions. 

Pediculus  pubis  or  inguinalis  (the  crab  louse)  is  about  ^3-  of  an  inch 
(i  mm.)  in  length,  yellowish-gray  in  color  and  possesses  six  legs  with  strong 
claws.  The  parasite  infests  the  hairy  parts  of  the  body  such  as  the  pubic 
region,  the  chest  and  axillae;  it  may  also  reach  the  beard  and  eyebrows.  Like 
the  preceding  parasites  it  causes  itching  and  irritation. 

Treatment  consists  in  the  application  of  mercurial  ointment  or  the  oint- 
ment of  ammoniated  mercury.  Beta  naphthol,  15  grains  (i.o)  to  the  ounce 
(30.0)  of  vaseline  is  also  effective.     Shaving  the  hair  may  be  necessary. 

Cimex  lectularius  (the  bed  bug)  is  a  flat  brown  insect  from  -^2  to  |-  of  an 
inch  (2  to  5  mm.)  in  length  and  slightly  less  in  breadth.  It  infests  beds  and 
the  cushions  of  public  vehicles  and  possesses  a  characteristic  and  unpleasant 
odor.  It  subsists  upon  the  blood  which  it  sucks,  and  causes,  in  most  persons, 
a  troublesome  itching  and  irritation  of  the  skin.  Certain  individuals  appear 
to  be  indifferent  to  or  immune  from  its  attacks.  The  female  lays  about  50 
ova  several  times  a  year  in  the  crevices  of  furniture  and  walls. 

Treatment.  The  irritation  of  the  bite  of  cimex  lectidarius  may  be  relieved 
by  antipruritic  lotions.  To  rid  furniture  and  apartments  of  the  pest  fumiga- 
tion with  sulphur,  and  painting  of  crevices  in  walls,  floors  and  elsewhere  with 
I  to  500  mercury  bichloride  solution,  kerosene,  or  a  mixture  of  oil  of  cedar 
I  part,  spirit  of  turpentine  or  methyl  alcohol  8  parts,  are  suggested. 

Pulex  Irritans  (the  common  flea)  is  found  almost  universally.  The  male 
is  about  y2  of  ^.n  inch  (2  mm.)  in  length  while  the  female  is  twice  this  size; 
in  color  the  insect  is  nearly  black  or,  when  filled  with  blood,  brownish. 

It  does  not  infest  man  naturally  but  may  do  so  in  districts  where  it  is  veiry 
abundant.  The  bite  is  very  irritating  to  susceptible  subjects,  being  evidenced 
by  a  slightly  raised,  circular  red  spot  in  the  center  of  which  the  insect's  proboscis 
has  entered;  other  individuals  may  suffer  no  inconvenience. 


PEDICULOSIS.  897 

Treatment.  The  irritation  may  be  relieved  by  soothing  applications.  Where 
the  insect  is  a  common  pest,  rubbing  the  skin  with  one  of  the  essential  oils 
such  as  that  of  pennyroyal  (hedeoma)  may  prevent  its  onslaughts. 

Pulex  penetrans  (the  sand-flea,  jigger  or  chigoe)  is  common  in  tropical 
countries  and  in  the  Southern  United  States.  It  is  considerably  smaller 
than  the  common  flea  and  is  brownish  in  color. 

The  parasite  bites  all  warm-blooded  animals,  including  man,  just  as  does 
the  common  flea.  Impregnated  females  burrow  into  the  tissues,  particularly 
those  of  the  feet,  where  they  mature  their  eggs,  the  abdomen  enlarging  during 
this  process  to  the  size  of  a  small  pea.  The  mature  ova  are  laid  while  the 
female  is  imbedded  in  the  flesh  of  the  host  and  escape  thence  into  the  dust 
of  the  ground  or  floor  where  they  hatch  into  larvae.  The  shell  of  the  parent 
when  dead  and  empty  of  eggs  usually  causes  no  further  trouble  although  at 
times  irritation,  abscesses  and  ulcers  have  been  observed  to  result.  If  the 
parasite  is  removed  from  the  host  she  extrudes  her  eggs  and  perishes  and  the 
eggs  so  laid  do  not  hatch  into  larvae. 

The  chigoe  does  not  often  produce  serious  lesions  but  infection,  gangrene 
and  even  death  may  result  indirectly  from  its  presence. 

Prevention  of  the  entry  of  the  parasite  may  be  accomplished  by  wearing 
high  shoes  and  closely  woven  stockings. 

The  insects  may  be  prevented  from  entering  dwellings  by  sprinkling  the 
floors  with  kerosene  or  naphthol. 

Treatment  consists  in  the  removal  of  the  parasite  by  means  of  a  dull  knife 
or  needle,  strict  asepsis  being  observed.  The  removal  is  also  an  important 
point  in  prophylaxis  for  the  eggs  are  continually  being  dropped  from  the  host 
who  thus  becomes  dangerous  to  his  associates.  If  infection  of  the  lesion 
has  taken  place  it  should  be  treated  by  the  usual  surgical  and  antiseptic 
methods. 


57 


INDEX. 


Abadie's  sign,  537 
Abasia  astasia,  847 
Abscess,  mediastinal,  672 

of  the  brain,  742 

of  the  liver,  438 

of  the  lung,  652 

of  the  spleen,  526 

paranephritic,  710 

perinephric,  710 
Acanthocephala,  877 
Acarus  scabiasi,  893 
Achylia  gastrica,  385 
Acromegaly,  859 
Actinomycosis,  136 

course  of,  136 

diagnosis  of,  137 

of  alimentary  tract,  136 

of  brain,  137 

of  lungs,  136 

of  skin,  137 

pathology,  136 

symptoms  of,  136 

treatment  of,  137 
Active  congestion  of  kidney,  679 
Acute  albuminuria,  677 

alcoholism,  308 

angioneurotic  cedema,  853 

anterior  poliomyelitis,  754 

arsenical  poisoning,  301 

articular  rheumatism,  114 

ascending  paralysis,  768 

atrophic  spinal  paralysis,  754 

Bright's  disease,  684 

bronchial  catarrh,  630 

bulbar  palsy,  767 

catarrhal  dysentery,  71 

gastritis,  347 

nephritis,  684 

desquamative  nephritis,  684 

dyspepsia,  347 

febrile  jaundice,  212 

gastric  catarrh,  347 

hydrocephalus,  729 

ileo-colitis,  394,  406 

leptomeningitis,  727 

miliary  tuberculosis,  159 

nasal  catarrh,  620 

nephritis,  684 

phthisis,  161 

poliomyelitis,  754 

rheumatism,  114 


Acute  softening  of  the  brain,  725 
tonsillitis,  340 
tracheo-bronchitis,  630 
tubal  nephritis,  684 
yellow  atrophy  of  the  liver,  454 
aetiology  of,  454 
definition  of,  454 
diagnosis  of,  455 
pathology  of,  454 
prognosis  of,  455 
symptoms  of,  455 
treatment  of,  455 
urine  in,  455 
Adams-Stokes  syndrome,  600 

treatment  of,  603 
Addison's  disease,  547 
aetiology  of,  547 
diagnosis  of,  54S 
pathology  of,  547 
prognosis  of,  548 
symptoms  of,  547 

coloration  of  skin,  547 
treatment  of,  548 
Adenitis,  malignant,  84 
tropical,  86 
tuberculous,  184 
Adiposis  dolorosa,  859 
Adipositas  universalis,  284 
^stivo-autumnal  fever,  54,  57 
Ageusia,  807 
Agraphia,  motor,  738 
Ainhum,  863 
Albuminoid  heart,  564 

liver,  451 
Albuminuria,  677 
extrarenal,  677 
general  remarks  on,  677 
physiological  or  functional,  678 
renal,  677 

immediate  cause  of,  677 
Albuminuric  retinitis,  693,  797 
Alcohol  poisoning,  308 
Alcoholic  coma,  309 
Alcoholism,  308 
acute,  308 

definition  of,  308 
diagnosis  of,  309 
symptoms  of,  309 
treatment  of,  310 
chronic,  310 

definition  of,  310 


899 


900 


INDEX. 


Alcoholism,  chronic,  effects  of,  310 
symptoms  of,  311 

digestive  apparatus,  311 
liver,  311 

nervous  sj'stem,  311 
vascular  changes,  311 
treatment,  312 
Allantiasis,  325 
Amaurosis,  798 
hysterical,  798 
methyl  alcohol,  316,  798 
tobacco,  798 
toxic,  798 
uraemic,  798 
Amblyopia,  798 

methyl  alcohol,  316 
tobacco,  798 
American  disease,  840 
Amok,  846 
Amoeba  coli,  74 
Amoebic  dysentery,  73 
Amuck,  846 

Amyloid  disease,  heart,  566 
liver,  451 

Etiology,  451 
definition  of,  451 
diagnosis  of,  452 
pathology,  451 
prognosis  of,  452 
symptoms  of,  452 
treatment  of,  452 
spleen,  527 
Amyotrophic  lateral  sclerosis,  759 
aetiology  of,  759 
pathology  of,  759 
symptoms  of,  759 
treatment  of,  760 
Anchylostomum  duodenale,  877 
Anchylostomiasis,  877 
Anaemia,  in  general,  500 
hepatic,  463 
infantum,  517 
aetiology  of,  517 
diagnosis  of,  518 
patholog}'  of,  517 
prognosis  of,  518 
symptoms,  519 
treatment  of,  519 
infantum  pscudo-leucaemica,  517 
lymphatic,  529 
aetiology,  529 
diagnosis  of,  531 
pathology  of,  530 
prognosis  of,  531 
symptoms  of,  530 
treatment  of,  531 
of  the  liver,  463 
primary  or  essential,  503 
chlorosis,  503 
aetiology  of,  503 
blood  in,  504 
cardiac  murmurs  in,  503 
definition  of,  503 


Anaemia,  chlorosis,  diagnosis  of,  504 
pathology  of,  503 
prognosis  of,  504 
symptoms  of,  503 
treatment  of,  504 
progressive  pernicious,  507 
cctiology  of.  507 
blood  in,  508 
definition  of,  507 
diagnosis  of,  508 
pathology  of,  507 
prognosis  of,  508 
symptoms  of,  508 
treatment  of,  508 
secondary  or  symptomatic,  500 
cardiac  murmurs  in,  501 
diagnosis  of,  502 

due  to  drain  of  chronic  disease,  500 
due  to  haemorrhage,  500 
from  inanition,  500 
symptoms  of,  501 
treatment  of,  502 
splenic,  5 28 

aetiology  of,  528 
diagnosis  of,  529 
pathology  of,  528 
prognosis  of,  529 
symptoms  of,  528 
treatment  of,  529 
toxic.  500 
Anaemias,  the,  500 

Aneurysm,  differential  diagnosis  of,  615 
from  aortic  incompetency,  615 
from  mediastinal  tumors,  615 
from  pulsating  empyema,  615 
of  the  abdominal  aorta,  615 
of  the  branches,  616 
of  the  coeliac  axis,  616 
of  the  aorta,  611 
of  the  ascending  aorta,  611 
of  the  descending  aorta  612 
of  the  heart,  568 
aetiology  of,  611 
false,  610 

dissecting,  610 
traumatic,  610 
true,  610 

varix  or  anastomotic,  610 
of  the  hepatic  artery,  616 
of  the  pulmonary  artery,  616 
of  the  renal  artery,  616 
of  the  splenic  artery,  616 
of  the  superior  mesenteric  artery,  616 
of  the  thoracic  aorta,  611 
diagnosis  of,  615 
physical  signs  of,  613 
diastolic  shock,  613 
symptoms  of,  611 
pain,  6  12 
pressure,  612 
tracheal  tugging,  614 
voice,  613 
of  the  transverse  part  of  aorta,  612 


INDEX. 


901 


Aneurysm,  physical  signs,  645 
prognosis  of,  615,  616 
treatment  of,  617 
varieties  of,  610 
Angina,  338 
follicularis,  340 
Ludovici,  338 
malignum,  87 
membranacea,  87 
pectoris,  603 
aetiology  of,  603 
diagnosis  of,  604 

from  hysterical  form,  604 
pathology  of,  604 
prognosis  of,  605 
symptoms  of,  604 
oppression,  604 
pain,  604 
paroxysm,  604 
treatment,  605 
Angioneurotic  oedema,  853 
cetiology  of,  853 
pathology  of,  853 
symptoms  of,  853 
treatment  of,  854 
Anguillula  acetici,  876 
Anguillulina  putrefaciens,  876 
Anorexia  nervosa,  392 

treatment  of,  392 
Anosmia,  791 
Anterior  poliomyelitis,  acute,  754 

chronic,  757 
Anthrax,  131 
aetiology  of,  131 
bacillus,  132 
diagnosis  of,  133 
external,  132 

malignant,  oedema,  132 
pustule,  132 
in  animals,  131 
incubation,  132 
internal,  132 

intestinal  anthrax,  132 
wool-sorter's  disease,  133 
pathology  of,  132 
prognosis  of,  133 
symptoms  of,  132 
treatment  of,  133 
Antimonial  poisoning,  305 
acute,  305 

treatment  of,  305 
chronic,  305 

treatment  of,  305 
Antitoxin,  diphtheria,  93 
technique  of  injection  of,  93 
untoward  effects  of,  94 
Aortic  incompetency,  579 
insufficiency,  579 
aetiology  of,  5  So 
physical  signs  of,  581 
capillary  pulse,  582 
Corrigan  pulse,  582 
Flint  murmur  in,  581 


Aortic  insufficiency,  symptoms  of,  580 
treatment  of,  592 
obstruction,  582 
aetiology  of,  582 
diagnosis  of,  583 
physical  signs,  582 
symptoms  of,  5S2 
treatment  of,  592 
Aphasia,  737 
motor,  738 

or  loss  of  faculty  of  speech,  738 
sensory,  737 

various  forms  of,  737,  738 
Aphthae  epizooticae,  139 
Aphthous  fever,  139 
Apoplexy,  731 

cerebral  haemorrhage,  731 
cetiology  of,  731 
arterial  distribution,  731 
diagnosis  of,  733 
pathology  of,  731 
symptoms  of,  732 
treatment  of,  734 
embolism  and  thrombosis  of  the  cerebral 
arteries,  735 
etiology  of,  735 
diagnosis  of,  733 
pathology  of,  735 
relative  frequency,  733 
symptoms  of,  734 
treatment  of,  734 
meningeal,  785 
Appendicitis,  412 
aetiology  of,  412 
bacilli,  413 
catarrhal,  413 
definition  of,  412 
diagnosis  of,  415 
exciting  causes,  412 
morbid  anatomy  of,  412 
of  catarrhal,  412 
of  gangrenous,  414 
of  ulcerative,  414 
obhterative,  413 

pathology  and  morbid  anatomy,  413 
predisposing  causes,  412 
prognosis  of,  415 
symptoms  of,  414 

rigidity  of  muscle,  415 
tenderness,  415 
tumor,  415 
treatment  of,  415 
diet,  416 
medicinal,  416 
operative,  417 
Arachnidae,  893 

Argyll-Robertson  pupil,  762,  799 
Arrhythmia,  600 

treatment  of,  603 
Arithmomania,  819 
Arsenical  poisoning,  301 
acute,  301 

symptoms  of,  301 


go  2 


INDEX. 


Arsenical  poisoning,  acute,  treatment  of,  301 
chronic,  302 

symptoms  of,  302 
treatment  of,  303 
Arterio-capillary  fibrosis,  606 
Arteriosclerosis,  606 
aetiology  of,  606 
pathology  of,  606 
symptoms  of,  607 
treatment  of,  60S 
coronary,  566 
Arthritis  deformans,  2S0 
aetiology  of,  280 
definition  of,  2S0 
diagnosis  of,  282 
pathology  of,  280 
prognosis  of,  283 
symptoms  of,  281 
multiple,  281 

partial  or  monarticular,  2S2 
treatment  of,  2S3 
vertebral  t3'pe  of,  282 
Arthritis,  gonorrhoeal,  142 
Arthropoda,  893 
Arachnoidea,  893 

linguatulidea  or  pentastomes,  463,  894 
insecta,  893,  S94,  895 
Ascariasis,  872 
Ascaris  alata,  875 
canis,  875 
lumbricoides,  872 
mystax,  875 
trichiura,  876 
Ascites,  497 

aetiology  of,  497 
character  of  fluid,  498 
chylous,  498 

differential  diagnosis  of,  498 
from  cyst  of  the  omentum,  499 
from  hydronephrosis,  499 
from  overdistended  bladder,  499 
from  ovarian  cyst,  498 
physical  signs  of,  498 
symptoms  of,  497 
treatment  of,  499 
Astasia-abasia,  847 
Asthenic  bulbar  paralysis,  857 
Asthma,  bronchial,  638 
cardiac,  576,  580 
ura?mic,  682 
Ataxia,  hereditary,  766 
cerebellar,  767 
progressive  locomotor,  760 
Ataxic  paraplegia,  766 
family,  766 
hereditary,  766 
Atheroma  of  the  blood-vessels,  606 
Athyrea,  541 

Atrophia  musculorum  lipomatosa,  866 
Atrophy,  acute  yellow,  of  the  liver,  454 
a:tiology  of,  454 
diagnosis  of,  455 
pathology  of,  454 


Atrophy,  symptoms  of,  455 
treatment  of,  455 

cardiac,  564 

facio-scapulo-humeral  type  of,  868 

juvenile   Erb's  form  of,  867 

progressive,  peroneal  type  of,  868 
Auditory  hyperaesthesia,  804 

irritation,  S04 

or  eighth  nerve,  lesions  of,  804 
Aucnbrugger's  sign,  552 
Aural  vertigo,  805 
Autumnal  catarrh,  621 

fever,  10 

Babinski  reflex,  107 
Baccelli's  sign,  660 
Bacillary  dysentery,  72 
BaciUus  dysenteriae,  72 
Bacillus  pestis,  84 
Bacillus  pneumoniae,  191 
Bacillus  typhosus,  10 
Bacteriaemia,  120 
Banti's  disease,  528 
Barlow's  disease,  290 
Basedow's  disease,  536 
Beaumes's  sign,  604 
Bechterew's  sign,  762 
Bedbug,  896 
Beef  tape-worm,  887 
Behier-Hardy's  sign,  655 
BeU's  palsy,  801 
Bends,  773 
Berger's  sign,  762 
Beri-beri,  206 

aetiology  of,  207 

diagnosis  of,  208 

pathology  of,  207 

prognosis  of,  208 

symptoms  of,  207 

treatment  of,  208 
Big  jaw,  136 
Bile-ducts,  carcinoma,  482 

parasites,  483 

stenosis,  482 

common,  inflammation  of,  466 
Bile-passages  and  gall-bladder,  diseases  of, 

466 
Bilharzia  haematobium,  871 
Bilharziosis,  871 
Biliary  cancer,  481,  482 

calculus,  473 

colic,  475 

tract,  diseases  of,  466 
Bilious  headache,  854 

remittent  fever,  42 
Bisulphide  of  carbon  poisoning,  324 
Black  death,  33,  84 

plague,  ss,  84 

vomit,  43 
Black-water  fever,  59 
Bladder,  tuberculosis  of,  188 

worms,  887 
Blastomycosis,  137 


INDEX. 


903 


Blastomycosis,  aetiology  of,  138 
pathology  of,  13S 
symptoms  of,  13S 
treatment  of,  139 
Blepharospasm,  803 
Blindness  due  to  methyl  alcohol,  316 
Blood,  diseases  of  the,  500 
Blood-vessels,  diseases  of,  610 

tuberculosis  of,  190 
Bloody  flux,  70 
Boas's  sign,  370 
Body  louse,  895 
Bone  tumor,  136 
Bordier-Frankel's  sign,  802 
Borism,  307 

symptoms  of,  307 
treatment  of,  308 
Bothriocephalus  latus,  888 

Mansoni,  8S9 
Botulismus,  325 
Boutillau's  sign,  558 
Bouveret's  sign,  422 
Bowel,  carcinoma  of,  432 
diagnosis  of,  432 
symptoms  of,  432 
treatment  of,  433 
embolic  ulcer  of,  412 
haemorrhagic  infarct  of,  409 
intussusception  of,  419 
invagination  of,  419 
nervous  affections  of,  429 
derangement  of  motion,  430 

of  sensibility,  431 
enteralgia,  431 
secretion  neurosis,  431 
treatment  of,  397 
obstruction  of,  417 
by  faecal  matter,  421 
by  foreign  bodies,  421 
by  morbid  growths,  421 
by  stricture,  421 
strangulation  of,  418 
syphilitic  ulcer,  412 
twists  and  knots  in,  418 
ulceration  of,  410 
Brach-Romberg's  symptom,  see  Romberg's 

symptom,  p.  762 
Brachial  plexus,  lesions  of,  787 
Bradycardia,  599 
explanation  of,  599 
treatment  of,  602 
Brain,  abscess  of,  742 
aetiology  of,  742 
complications  of,  743 
pathology  of,  742 
prognosis  of,  744 
symptoms  of,  743 
treatment  of,  744 
affections  of  the  blood-vessels  of,  735,  737 

diseases  of,  725 
and  its  membranes,  diseases  of,  732 
railway,  847 
sclerosis  of,  740 


Brain,  tumors  of  the,  744 
aetiology  of,  744 
diagnosis  of,  745 
prognosis  of,  748 
symptoms  of,  744 

of  basal  ganglia  or  internal  capsule, 

748 
of  base  of  the,  748 
of  central  or  motor  region,  746 
of  cerebellum,  750 
of  corpora  quadrigemina,  748 
of  corpus  callosum,  74S 
of  crura,  748 
of  occipital  lobe,  747 
of  parietal  area,  747 
of  pons  and  medulla  oblongata,  747 
of  prefrontal  area,  746 
of  tcmporosphenoidal  area,  747 
treatment,  748 
varieties  of,  744 
wet,  311 
Breakbone  fever,  52 
Brickmaker's  anaemia,  877 
Bright's  disease,  acute,  684 

chronic,  691 
Broadbent's  sign,  555 
Bromism,  306 

symptoms  of,  306    . 
treatment  of.  307 
Bronchi,  diseases  of,  630 
Bronchial  asthma,  638 
aetiology  of,  638 
physical  signs  in,  639 
prognosis  of,  639 
symptoms  of,  638 
treatment  of,  639 
catarrh,  acute,  630 

chronic,  634 
dilatation.  641 
tubes,  diseases  of,  636 
Bronchiectasis,  641 
aetiology  of,  641 
diagnosis  of,  642 
pathology  of,  641 
physical  signs  of,  642 
symptoms  of,  642 
treatment  of,  643 
Bronchitis,  630 
acute,  630 

aetiology  of,  630 
pathology  of,  631 
physical  signs  of,  631 
symptoms  of,  631 
treatment  of,  632 
capillary,  198 
chronic,  634 
aetiology  of,  634 
diagnosis  of,  635 
pathology  of,  634 
physical  signs  of,  635 
prognosis  of,  635 
symptoms  and  course  of,  634 
treatment  of,  635 


904 


INDEX. 


Bronchitis,  chronic,  chmatic  resorts,  635 
foetid,  635 

plastic  or  fibrinous,  636 
aetiology  of,  637 
diagnosis  of,  637 
pathology  of,  637 
physical  signs  of,  637 
symptoms  of,  637 
treatment  of,  637 
putrid,  635 
spasmodic,  638 
astiology  of,  638 
pathology  of,  638 
physical  signs  of,  639 
symptoms  of,  638 
treatment  of,  639 
Bronchocele,  534 
Broncho-pneumonia,  198 
Brown  atrophy  of  the  heart,  564 
Bubo,  climatic,  86 
symptoms,  86 
treatment,  87 
tropical,  86 
Bubonic  plague,  84 
aetiology  of,  84 
bacillus  of,  84 
diagnosis  of,  85 
pathology  of,  84     « 
prognosis  of,  85 
symptoms  of,  84 
treatment  of,  85 

serum  therapy,  86 
varieties  of,  86,  87 
bubonic  form,  85 
pestis  minor,  84 
pestis  major,  85 
pneumonic  form,  85 
septicaemia  form,  85 
Buhl's  disease,  521 
Bulbar  paralysis,  767 
aetiology  of,  767 
pathology  of,  7  68 
prognosis  of,  768 
symptoms  of,  768 
treatment  of,  768 
Bulimia,  391 

treatment  of,  391 
Burton's  sign,  298 
Busk's  fluke,  872 

Cachexia,  malarial,  59 

thyroidea  vel  strumipriva  vel  thyreopriva, 

541 
Caisson  disease,  773 

aetiology  of,  773 

pathology  of,  773 

prevention  of,  775 

symptoms  of,  774 

treatment  of,  776 
Calcareous  degeneration  of  heart,  566 
Calculi,  pancreatic,  489 
Calculus,  biliary,  473 

hepatic,  473 


Calculus,  renal,  711 
Calliphoria  vomitoria,  894 
Camp  fever,  33 
Cancer,  gastric,  369 
of  the  gall-bladder,  481 
of  the  liver,  456 
of  the  oesophagus,  344 
of  the  pancreas,  487 
of  the  pericardium,  556 
of  the  peritonaeum,  496 
of  the  stomach,  369 
Cancrum  oris,  334 
Cannabis  indica  poisoning,  322 
Capillary  bronchitis,  198 
Carbon  disulphide  poisoning,  324 
symptoms  of,  324 
treatment  of,  324 
Carcinoma  of  the  bowel,  432 
of  the  liver,  456 
diagnosis  of,  458 
massive  form,  456 
nodular  form,  456 
treatment  of,  459 
with  cirrhosis,  457 
of  the  lung,  652 
of  the  stomach,  369 
ventriculi,  369 
Cardarelli's  sign,  616 
Cardiac  arrhythmia,  600 
atrophy,  564 
dilatation,  559 
defects,  congenital,  586 

treatment  of,  598 
disease,  556 

muscle,  degeneration  of,  564 
albuminoid.  564 
amyloid,  566 
calcareous,  566 
hyaline,  566 
neuroses,  598 
Cardiospasm,  3S6 

treatment  of,  38 7 
Cardiothyroid  exophthalmos,  536 
Case  record,  3 

Catarrh,  acute  bronchial,  630 
chronic  bronchial,  634 
nasal,  620 
Catarrhal  fever,  47 
pneumonia,  198 
Catarrhus  aestivus,  621 
Cellulitis  of  the  neck,  338 
Cephalodynia,  279 
Cerebellar  hereditary  ataxia,  767 
Cerebellum,  disease  of,  749 
tumors  of,  749 
symptoms,  749 
Cerebral  disease,  725 
embolism,  735 

localizations  of,  746 

summary  of  facts  bearing  on,  746 
hemorrhage,  731 
meningitis,  726 
softening,  735 


INDEX. 


905 


Cerebral  thrombosis,  735 
Cerebritis,  acute,  725 

suppurative,  742 
Cerebrospinal  fever,  104 

aetiology  of,  105 

Babinski's  reflex  in,  107 

brain  in,  105 

complications  and  sequelae,  108 

cranial  nerves  in,  105 

diagnosis  of,  108 

from  tuberculous  meningitis,  109 

forms  of,  107 
abortive,  107 
chronic    107 
intermittent,  107 
malignant,  107 
mild,  107 
ordinary,  106 

incubation  period,  106 

Kernig's  sign  of,  107 

lumbar  puncture  in,  108,  109 

pathology  of,  105 

predisposing  causes  of,  105 

prognosis  of,  109 

Quincke's  lumbar  puncture  in,  108,  109 

spinal  cord  in.  105 

symptoms  of,  106 

treatment  of,  109 
Cestodes,  887 

Charcot-Leyden  crystals,  165 
Charcot's  disease,  759 

symptom,  608 
Cheese  poisoning,  326 
Chiasm  and  tract,  lesion  of,  795 
Chicken-pox,  240 

complications  in,  241 

varicella  gangrenosa,  241 

eruption  in,  240 

incubation  in,  240 
Chick-pea  disease,  328 
Chigoe,  897 

Children,  reflex  convulsions  of,  831 
Chill,  the  congestive,  59 
Chills  and  fever,  56 
Chloraemia,  503 
Chloral  poisoning,  317 
Chloralism,  317 

symptoms  of,  317 

treatment  of,  317 
Chloranaemia,  503 

Chloride  retention  in  chronic  nephritis,  694 
Chloroma,  516 
Chlorosis,  503 

aetiology  of,  503 

blood  in,  504 

definition  of,  503 

diagnosis  of,  504 

pathology  of,  503 

prognosis  of,  504 

symptoms  of,  503 

treatment  of,  504 
Choked  disk,  796 
Cholecystitis,  acute  infectious,  471 


Cholecystitis,  aetiology  of,  471 
definition  of,  471 
diagnosis  of,  472 
pathology  of,  471 
symptoms  of,  472 
treatment  of,  472 
Cholelithiasis,  473 
aetiology  of,  473 
diagnosis  of,  478 
symptoms  of,  474 
treatment  of,  478 
Cholera,  64 
aetiology  of,  64 
bacillus  of,  64 

of  Koch,  64 
collapse  in,  66 
diagnosis  of,  67 

diS^erentiation  from  cholera  morbus,  67 
epidemics  of,  64 
mode  of  infection,  65 
pathology  of,  65 
prevention  of,  67 
prognosis  of,  67 
sicca,  66 
symptoms  of,  66 

incubation,  66 
stage  of  collapse,  66 

of  preliminary  diarrhoea,  66 
of  reaction,  67 
treatment  of,  68 

enteroclysis,  69 

of  attack,  68 

protective  inoculation,  70 
algida,  64 
Asiatica,  64 
infantum,  404 

aetiology  of,  404 

definition  of,  404 

pathology  of,  404 

prognosis  of,  405 

symptoms  of,  404 

treatment,  405 
maligna,  64 
morbus,  400 

aetiology  of,  400 

definition  of,  400 

pathology  of,  400 

prognosis  of,  401 

symptoms  of,  400 

treatment  of,  401 
nostras,  400 
sporadic,  400 
Cholerine,  67 
Chorea,  acute,  814 

aetiology  of,  814 

pathology  of,  815 

nature  of,  814 

prognosis  of,  816 

symptoms  of,  815 

treatment  of,  816 
chronic  hereditary,  820 

aetiology  of,  820 

pathology  of,  820 


9o6 


INDEX. 


Chorea,  chronic  hereditary,  prognosis  of,  821 
symptoms  of,  820 
treatment  of,  82 1 

habit,  819 

hereditary,  820 

Huntington's,  820 

mild,  815 

minor,  814 

Sydenham's,  820 
Choreiform  affections,  818 
Chovostek's  symptom,  834 
Chronic  anterior  poHomyelitis,  757 

bronchial  catarrh,  634 

catarrhal  dyspepsia,  350 
gastritis,  350 
cyanosis,  517 

diarrhoea,  396 

diffuse  meningo-encephalitis,  738 
nephritis,  6gi 

endocarditis,  574 

gastric  catarrh,  350 

interstitial  hepatitis,  442 

pneumonia,  203 

malaria,  59 

parenchymatous  nephritis,  681 

rheumatic  arthritis,  276 

tubal  nephritis,  6S1 

ulcerative  phthisis,  162 

valvular  disease,  574 
Chronically  contracted  kidney,  691 
Chyluria,  722,  884 
Cimex  lectularius,  896 
Cirrhosis  of  the  liver,  442 

cTtiology,  442 

definition  of,  442 

diagnosis  of,  444 

pathology  of,  443 

prognosis  of,  445 

symptoms  of,  443 

treatment  of,  445 
diet  in,  449 
Cirrhosis  of  the  lung,  201 
Cirrhotic  kidney,  696 
Clark's  sign,  492 
Claudication,  intermittent,  608 
Climate  in  tuberculosis,  173 
Cocaine  poisoning,  322 
Cocainism,  322 

symptoms  of,  323 

treatment  of.  323 
Coccidium  cuniculi,  869 

hominis,  86g 

oviforme,  463,  869 
Cold  in  the  head,  acute,  620 
Colic,  biliary,  475 

hepatic,  475 

lead,  297 

renal,  713 
Colica  pictonum,  297 
Colitis,  mucous,  396 

ulcerative,  396 
Colles'  law,  146 
Colon,  dilatation  of,  429 


Combined  valvular  lesions,  586 
Comedo  mite,  893 
Compressed  air  disease,  773 

treatment  of,  776 
Compression  of  spinal  cord,  778 

a;tiology  of,  778 

pathology  of,  778 

symptoms  of,  7 78 

treatment  of,  779 
Compression  myelitis,  778 
Compsomyia  maceilaria,  894    ■ 
Congenital  absence  of  kidney,  674 

cardiac  defects,  586 
treatment  of,  598 
Congestion  of  the  kidney,  679 
Congestive  chill,  59 
Constipation,  424 

treatment  of,  425 
in  infants,  428 
Constitutional  diseases,  256 
Consumption,  galloping,  161 

of  the  lungs,  160 
Contracted  kidney,  696 
Convulsions,  reflex,  in  children,  831 
Convulsive  tic,  S19 
Copodyscinesia,  84S 
Coprolalia,  819 
Cor  adiposum,  565 

Cord,  spinal,  diseases  of  membranes  of,  750 
Coronary  arteries,  sclerosis  of,  566 
Corpulence,  2SS 
Corrigan  pulse,  5S2 
Cortical  epilepsy.  823 
Coryza,  acute,  620 
Costiveness,  424 
Country  fever,  331 
Coup  de  soleil,  330 
Courvoisier's  law,  474 
Cow-pox,  253 
Crab  louse,  895 
Cramps  of  cardia,  3S8 
Cranial  nerves,  diseases  of,  794 
Cretinism,  542 

congenital,  542 

endemic,  543 

sporadic,  543 

treatment  of,  543 
Cretinoid  idiocy,  542 
Crises,  tabetic,  762 
Croup,  catarrhal,  519 

false,  626 

membranous,  87 

spasmodic   626 
treatment  of,  626 
Croupous  enteritis,  408 

pneumonia,  190 
Curschmann's  spirals,  639 
Cyanosis,  chronic,  517 
Cyclic  vomiting,  392 

treatment  of,  393 
Cvcloplegia,  798 
Cysticerci,  887 
Cysticercus  cellulosas,  463 


INDEX. 


907 


Cysts,  echinococcus,  460 

hydatidosus,  460 

of  kidney,  718 

of  spleen,  528 

of  the  pancreas,  487 
Cytozoa,  869 

Dairy  products,  poisoning  by,  326 
Dance's  sign,  420 
Dandy  fever,  52 

Davainea  Madigascariensis,  890 
Deafness,  nervous,  805 
Dechloridation  treatment,  694 
Degeneration  of  the  heart,  amyloid,  566 
calcareous,  566 
fatty,  or  metamorphosis,  565 

circumscribed.  565 
parenchymatous  or  albuminoid   (cloudy 
swelling),  564 
Delire  du  toucher,  819 
Delirium  cordis,  601 
tremens,  313 

definition  of,  313 
diagnosis  of,  314 
prognosis  of,  314 
symptoms  of,  313 
treatment  of,  314 
Dementia  paralytica,  738 
aetiology  of,  739 
pathology  of,  739 
prognosis  of,  740 
symptoms  of   739 
treatment  of,  740 
Demodex  folliculorum,  893 
De  Mussey's  sign,  657 
Dengue,  52 
aetiology  of,  52 
diagnosis  of,  53 
pathology  of,  53 
prognosis  of,  53 
symptoms  of,  53 
treatment  of,  54 
Derbyshire  neck,  534 
Dercum's  disease,  859 
Dermacentor  reticulatus,  32 
Dermatosclerosis,  862 
Diabetes  insipidus,  273 
aetiology  of,  273 
definition  of,  273 
diagnosis  of,  274 
pathology,  273 
physical  and  chemical  character  of  the 

urine,  274 
prognosis  of,  274 
symptoms  of,  274 
duration  of,  274 
treatment  of,  274 
hygienic,  275 
medicinal,  275 
mellitus,  265 
aetiology  of,  266 
alimentary  form  of,  266 
beta  oxybutyric  acid  in,  268 


Diabetes  mellitus,  coma  in,  268 
definition  of,  265 
nervous  form  of,  266 
pancreatic  form  of,  266 
pathogenesis  of,  266 
pathology  of,  267 
prognosis  of,  268 
surgery  in,  273 
symptoms  of,  267 
boils  in,  267 
eczema,  267 
gangrene,  268 
lungs  in,  267 
polyuria,  267 
prognosis  of,  26S 
thirst,  267 
uric  acid,  267 
treatment  of,  2  68 
beverages  in,  271 
diabetic  coma,  272 
dietetic,  270 
hygienic,  272 
medicinal,  269 
potatoes  in,  271 
Diarrhoea,  acute,  394 
chronic,  396 
hill,  81 

of  children,  402 
summer,  402 
Diazo-reaction    15 
Dibothriocephalus  latus,  888 

cordatus,  889 
Dichotophyme  gigas,  876 
Dietl's  crisis,  675 
Digestants,  artificial,  353 
Digestive  system,  and  peritonaeum,  diseases 

of,  333 
Dilatation,  bronchial,  641 
of  the  colon,  429 

symptoms  of,  429 

treatment  of,  429 
of  the  heart,  559 
Diphtheria,  87 
aetiology  of,  87 
complications  and  sequelae,  90 

broncho-pneumonia,  90 

capillary  bronchitis,  90 

heart,  90 

nephritis,  90 

paralysis,  91 

toxic  neuritis,  91 
contagiousness  of,  88 
diagnosis  of,  91 
forms  of,  89,  90 
in  animals,  88 
Klebs-Lofiler  bacillus,  88 
laryngeal,  89 
nasal  type,  89 
pathology  of,  88 
pharyngeal  type,  89 
prognosis  of,  91 
prophylaxis  of,  91 
symptoms  of,  89 


go8 


INDEX. 


Diphtheria,  symptoms  of,  laryngeal  cough, 
89 
of  nasal,  89 

period  of  incubation,  89 
seats  of  invasion,  88 
treatment  of,  93 
antitoxin,  93 
administration  of  antitoxin  for  immun- 
ization, 92,  93 
of  complications  and  sequelae,  96,  97 
prophylactic,  93 
serum  therapy,  93 
Diphtheritic  enteritis,  408 
Diplococcus  intracellularis  meningitidis,  105 

pneumoniae,  191 
Dipsomania,  310 
Diptera,  894 

Dipylidium  caninum,  889 
Disinfection  after  contagious  diseases,  247 
Disseminated  sclerosis,  740 
aetiology  of,  740 
pathology  of,  740 
prognosis  of,  742 
symptoms  of,  741 
treatment  of,  741 
Distomiasis,  870 
intestinal,  872 
of  liver,  870 
of  blood,  871 
pulmonary,  870 
Distomum  Buskii,  872 
hepaticum,  S70 
pulmonale,  870 
Diver's  paralysis,  773 
Double  vision  in  disease  of  motor  nerves  of 

the  eye,  799 
Dracontiasis,  885 
Dranunculus  medinensis,  885 
Drummond's  sign,  614 
Duchenne's  disease,  760 
Ductless  glands,  diseases  of,  525 
Dukes's  disease,  239 
Dum-dum  fever,  217 
Duodenal  ulcer,  410 
Duodeno-cholangitis,  466 
Dysaesthesia,  804 
Dysentery,  70 
amoebic,  73 
aetiology  of,  73 
complications,  75 
diagnosis  of,  76 
prognosis  of,  76 
symptoms  of,  75 
treatment  of,  76 
bacillary,  72 
catarrhal,  71 
aetiology  of,  71 
diagnosis  of,  72 
pathology  of,  71 
symptoms  of,  71 
treatment  of,  76 
chronic,  396 

pathology  of,  397 


Dysentery,  chronic,  treatment  of,  397 
diphtheritic,  76 

pathology  of,  76 

symptoms  of,  76 

vaccines,  407 
epidemic,  72 
sporadic,  71 

treatment  of,  76 
tropical,  72 

aetiology  of,  72 

complications  of,  73 

diagnosis  of,  73 

pathology  of,  72 

prognosis  of,  73 

symptoms  of,  73 

treatment  of,  76 
Dyspepsia,  347 
acute,  347 
atonic,  374 
chronic,  330 
flatulent,  389 

Echinococcus  disease,  887 
Echinococcus  disease  of  liver,  460 

Ktiology  of,  460 

symptoms  of,  461 

treatment  of,  462 
Echinorhynchus  gigas,  877 

moniliformis,  877 
Echolalia,  819 
Echokinesis,  819 
Eclampsia,  infantile,  831 

puerperal,  832 
treatment  of,  833 

urasmic,  6S2 
Eczema  of  tongue,  335 
Effects  of  exposure  to  high  temperatures, 

329 
Egyptian  chlorosis,  877 
Ehrlich's  diazo-reaction,  15 
Eighth  nerve,  lesions  of,  804 
Elephantiasis  graecorum,  210 
Eleventh  nerve,  lesions  of,  810 
Embolic  pneumonia,  205 

non-septic,  205 

septic,  205 
Embolism  of  cerebral  vessels,  735 

of  portal  vein,  465 
Emphysema,  pulmonary,  644 

aetiology  of,  645 

atrophic,  645 

compensatory,  645 

interlobular  or  interstitial,  644 

senile,  645 

vesicular,  645 

diagnosis  of,  646 

pathology  of,  645 

physical  signs  of,  646 

prognosis  of,  646 

symptoms  of,  646 

treatment  of,  646 
Empyema,  663 

aetiology  of,  663 


INDEX. 


909 


Empyema,  pathology  of,  663 
physical  signs  of,  664 
prognosis  of,  664 
symptoms  of,  663 
treatment  of,  664 

operation  in,  664 
Encephalitis,  acute,  725 

aetiology  of,  725 

pathology  of,  725 

prognosis  of,  726 

symptoms  of,  725 

treatment  of,  726 
suppurative,  742 
Encephalopathia  saturnalis,  299 
Endarteritis,  chronic,  606 
Endocarditis,  acute,  mild  or  simple  form, 
669 

aetiology  of,  669 

diagnosis  of,  672 

pathology  of,  670 

prognosis  of,  672 

S3Tnptoms  of,  671 

treatment  of,  672 
chronic,  574 

aetiology  of,  574 

definition  of,  574 

pathology  of,  574 

prognosis  of,  585 

treatment  of,  585 
evere  or  malignant  form,  569 

aetiology  of,  569 

diagnosis  of,  572 

pathology  of,  570 

prognosis  of,  572 

symptoms  of,  571 

treatment  of,  573 
Endocardium,  diseases  of,  569 
Enteric  fever,  7 
aetiology  of,  7 
albuminuria  in,  12,  16 
ambulatory  form  of,  8,11 
antiseptic  treatment  of,  17,  23 
bacteriology  of,  7 
bath  treatment  of,  19 
bed  sores  in,  14 
blood  changes  in,  14 
boils  in,  14 
bone  lesions  in,  14 
cardiac  complications  in,  14 
chills  in,  10,  11 
chlorine  in  treatment  of,  18 
cholecystitis  in,  14 
circulatory  system  in,  10,  25 
clinical  chart  of,  9 
complications  in,  13 
constipation  in,  12 
contagiousness  of,  7 
course  of,  8 

Currie-Jiirgensen  bath  in,  19 
delirium  in,  11,  12 
diagnosis,  14,  15 
diazo-reaction  of  urine  in,  15 
diet  in,  16,  27 


Enteric  fever,  disinfection  in,  15 

of  stools  in,  15 
Ehrlich's  reaction  in,  15 
eliminative  and  antiseptic  treatment  of ,  17 
eruption  of,  8 
facies  of,  10 
haemorrhage  in,  13 
in  children,  7,  19 
incubation  of,  8 

indications  for  alcohol  in,  20,  25 
influence  of  age  on,  7 

of  seasons  on,  7 
inoculation  against,  16 
leucocytes  in,  14 

management  of  convalescence  in,  27,  28 
meteorism  in,  8 

methods  of  reducing  temperature  in,  19 
milk  leg  in,  8,  13 
mode  of  conveyance  of,  7 
nervous  or  meningeal  form  of,  1 1 
parotitis  in,  13 
pathology  of,   7 
perforation  in,  13 
peritonitis  in,  13 
Peyer's  patches  in,  7 
predisposing  causes  of,  7 
prodromal  symptoms,  8 
prophylaxis  in,  15 
pulmonary  form,  13 
relapses  in,  10 
renal  form,  1 1 
rose-colored  spots  in,  8 
sequelae  of,  13 
serum -therapy  in,  17 
skin  rashes  in,  8 
specific  treatment  of,  17 
splenic  enlargement  in,  11 
symptoms  of,  8 
temperature  in,  9 
thrombosis  in,  8,  13 
tongue  in, 1 1 
treatment  of,  16 

by  cultures  of  serum,  17 

of  complications,  26 

of  convalescence,  27,  28 

of  special  symptoms,  24 
tympanitic  distention  in,  8 
typhoid  spine  in,  14 
unusual  forms  of  onset,  1 1 
urine  in,  15 
walking  form  of,  8,11 
Widal  reaction,  15 
Enteritis,  amoebic,   73 

acute  dyspeptic,  of  children,  402 

aetiology  of,  402 

pathology  of,  402 

prognosis  of,  403 

symptoms  of,  402 

treatment  of,  403 
chronic  catarrhal,  396 

aetiology,  396 

definition  of,  396 

pathology  of,  397 


9IO 


INDEX. 


Enteritis,  chronic  catarrhal,  prognosis  of,  397 

symptoms  of,  397 

treatment  of,  397 
croupous,  408 
diphtheritic,  408 
follicular,  406 
phlegmonous,  409 
pseudo-membranous,  408 

aetiology  of,  408 

definition  of,  408 

pathology  of,  408 

symptoms  of,  408 

treatment  of,  409 
simple  acute  catarrhal,  394 

aetiology  of,  394 

definition  of,  394 

diagnosis  of,  395 

pathology  of,  394 

symptoms  of,  395 

treatment  of,  395 
Enterocolitis,  acute,  406 

aetiology  of,  406 

definition  of,  406 

pathology  of,  406 

prognosis  of,  406 

symptoms  of,  406 

treatment  of,  407 
chronic,  396 
Enteroptosis,  379 
Ephemeral  fever,  210 
Epidemic  catarrhal  fever,  47 

jaundice,  212 
Epidemic  cerebrospinal  meningitis,  T04 
cholera,  64 
dysentery,  72 
parotitis,  97 
roseola,  229 
stomatitis,  139 
Epilepsia  acuta,  831 
Epilepsy,  821 
aetiology,  821 
pathology  of,  822 
physiology  of,  824 
prognosis  of,  824 
symptoms  of,  822 

of  clonic  spasm,  822 

of  coma,  822 

of  grand  mal,  822 

of  hysterical,  836 

of  Jacksonian,  823 

of  petit  mal,  823 

of  psychical,  823 

of  tonic  spasm,  822 
treatment  of,  824 

asylum,  827 

of  convulsion,  826 

Jacksonian,  823 

precursive  823 
Equilibrium,  disturbance  of,  associated  with 
defect  of  hearing,  905 
aetiology  of,  905 
prognosis  of,  906 
symptoms  of,  906 


Equilibrium,  disturbance  of,  treatment  of, 

906 
Erb's  form  of  juvenile  hereditary  atrophy, 
867 

symptom,  815 
Ergotism,  326 

symptoms  of,  326 

treatment  of,  327 
Erichsen's  disease,  847 
Eructation  of  gas,  nervous,  389 
Erysipelas,  in 

aetiology  of,  in 

bacillus  of,  112 

complications  of,  113 

diagnosis  of,  113 

facial,  112 

pathology  of,  112 

prognosis  of,  113 

relapses  and  recurrences  of,  113 

sequelae  of,  113 

symptoms  of,  112 
incubation,  112 

treatment  of,  113 

serum  in,  114 
Erythromelalgia,  852 

aetiology  of,  852 

pathology  of,  853 

prognosis  of,  853 

symptoms  of,  853 

treatment  of,  856 
Eustrongylus  gigas,  876 
E wart's  sign,  552 
Exophthalmic  goitre,  536 
Eyeball,  lesions  of  the  motor  nerves  of,  798 
Eyes,    phenomena   of    paralysis   of   motor 
nerves  of,  798,  799,  800 

Facial  hemiatrophy,  856 
aetiology  of,  856 
pathology  of,  857 
symptoms  of,  857 
treatment  of,  857 
nerve,  lesions  of,  801 
paralysis  of,  801 
aetiology  of,  801 
diagnosis  of,  802 
symptoms  of,  801 
treatment  of,  802 
spasm,  803 

aetiology  of,  803 
prognosis  of,  803 
symptoms  of,  803 

blepharospasm,  803 
treatment  of,  803 
Faecal  impaction,  421 
Falling  sickness,  821 
Fallopian  tubes,  tuberculosis  of,  189 
False  croup,  626 
Family  periodical  paralysis,  858 
Famine  fever,  39 
Farcy,  134 
acute,  135 
chronic,  135 


INDEX. 


911 


Fasciola  hepatica,  870 
Fasciolopsis  Buskii,  872 
Fascolidae,  870 
Fatty  degeneration  of  the  heart,  565 

infiltration  of  the  heart,  565 
of  the  liver,  450 
aetiology  of,  450 
diagnosis  of,  451 
pathology  of,  450 
prognosis  of,  451 
symptoms  of,  451 
treatment  of,  451 

metamorphosis  of  heart,  565 

myocarditis,  565 
Febricula,  210 

aetiology  of;  210 

diagnosis  of,  211 

symptoms  of,  210 

treatment  of,  211 
Febris  flava,  42, 
Fever,  Eestivo-autumnal,  58 

and  ague,  54 

aphthous,  139 

breakbone,  52 

bilious  remittent,  42 

camp,  33 

cerebrospinal,  104 

dandy,  52 

enteric,  7 

ephemeral-  210 

epidemic  catarrhal,  47 

famine,  39 

glandular,  212 

hospital,  33 

intermittent,  56 

intermittent  tick,  32 

irritative,  210 

jail,  33 

malarial,  54 

Malta,  37 

miliary,  213 

mountain,  29 

nasha,  63 

paludal,  54 

paratyphoid,  28 

pernicious  malarial,  59 

protracted,  idiopathic  continued,  211 

putrid,  32, 

relapsing,  39 

remittent,  58 

scarlet,  231 

ship,  33 

simple  continued,  211 

spotted,  29,  104 

swamp,  54 

tick,  32,  215 

typhoid,  7 

typhus,  S3 

yellow,  42 
Fibrinous  pneumonia,  190 
Fibroid  heart,  566 

phthisis,  169 
Fibrous  myocarditis,  566 


Fievre  inflammatoire,  331 
Fifth  nerves,  lesions  of,  boo 

paralysis  of  motor  portion,  800 
of  sensory  portion,  801 
Filaria  Bancroft!,  883 

diuma,  883 

hominis  oris,  886 

immitis,  886 

labialis,  886 

loa,  886 

medinensis,  885 

perstans,  883 

sanguinis  hominis,  883 

trachealis  et  bronchialis,  886 
Filariasis,  883 

treatment  of,  886 
Filatov's  spots,  226 
Fish  poisoning,  325 

treatment  of,  326 
Flea,  896,  897 
Flies,  parasitic,  894 
Flint  murmur,  579 
Floating  kidney,  675 

aetiology  of,  675 

diagnosis  of,  676 

symptoms  of,  675 

treatment  of,  676 
Florida  fever,  331 
Flukes,  870 

blood,  871 

Busk's,  872 

intestinal,  873 

liver,  870 

lung,  870 
Flush-tank  sign,  711 
Folie  pourquoi,  819 
Follicular  tonsillitis,  340 
Food  poisoning,  325 

treatment  of,  326 
Foot  and  mouth  disease,  139 

aetiology,  140 

incubation,  140 

prognosis  of,  140 

symptoms  of,  140 

treatment  of,  140 
Fourth  disease,  239 
Fourth  nerve,  lesions  of  the,  799 
Framboesia,  222 
Friinkel's  sign,  762 
Friedreich's  ataxia,  766 

aetiology  of,  766 

pathology  of,  766 

sign,  555 

symptoms  of,  766 

treatment  of,  767 
Functional    diseases    of    nervous    system, 

814 
Fungus  foot,  209 

Galactotoxismus,  326 

Gall-bladder,  acute  inflammation  of,  471 

cancer  of  481 

neoplasms  of,  481 


912 


INDEX. 


Gall  ducts,  neoplasms  of,  482 
parasites  of,  483 
stenosis  of,  482 
Gallop  rhythm,  600 
Galloping  consumption,  161 
Gall-stone,  473 
acute  impacted,  475 
diagnosis  of,  475 
prognosis  of,  475 
symptoms  of,  475 
chronic  impacted,  475 
diagnosis  of,  478 
results  of,  477 
symptoms  of,  475 

due  to   obstruction  of  the  common 

duct,  476 
due   to   chronic   obstruction  of   the 
cystic  duct,  475 
treatment  of,  478 
preventive,  478 
Gangrene  of  the  lung,  654 
symptoms  of,  654 
treatment  of,  655 
Gas,  nervous  eructation  of,  389 

treatment  of,  389 
Gastralgia,  390 
symptoms  of,  390 
treatment  of.  391 
Gastrectasis,  374 

acute,  377 
Gastric  cancer,  369 
catarrh,  acute,  347 

chronic,  350 
dilatation,  374 

acute,  377 
fever,  7,  347 
hypersesthesia,  389 
symptoms  of,  390 
treatment  of,  390 
hyperacidity,  3S2 
hyperperistalsis,  588 
symptoms  of,  588 
treatment  of,  588 
lavage,  352 
neuralgia,  390 
ulcer,  358 
Gastritis,  acute  catarrhal,  347 
aetiology  of,  347 
definition  of,  347 
pathology  of,  347 
stomach  contents  in,  347 
symptoms  of,  347 
treatment  of,  347 
chronic  catarrhal,  350 
aetiology  of,  350 
definition  of,  350 
pathology  of,  350 
stomach  contents  in,  351 
symptoms  of,  350 
treatment  of,  350 
dietetics  of,  355 
diphtheritic,  357 
mycotic,  357 


Gastritis,  phlegmonous  or  suppurative,  356 

traumatic  and  toxic,  356 
Gastrodiaphany,  375 
Gastrodiscus  hominis,  872 
Gastrodynia,  390 
Gastro-enteric  fever,  7 
Gastro-enteritis,  acute,  402 
aetiology  of,  402 
definition  of,  402 
pathology  of,  402 
symptoms  of,  402 
treatment  of,  403 
Gastrophilus  equi,  895 
Gastro-intestinal  catarrh,  402 
Gastroptosis,  379 
Gastroscopy,  375 
Gastrosuccorrhcea,  382 
Gastroxynsis,  382 
General  paralysis,  738 

paresis,  738 
Geographical  tongue,  335 
Gerlier's  disease,  218 
German  measles,  229 
Giant  urticaria,  853 
Gigantorhyncus,  877 
Gilles  de  la  Tourette's  disease,  819 
Gin  liver,  442 
Glanders  and  farcy,  134 
aetiology  of,  134 
diagnosis  of,  135 
incubation,  134 
pathology  of,  134 
prognosis  of,  136 
symptoms  of,  134 
treatment  of,  136 
Glands,  ductless,  diseases  of,  525 
Glandular  fever,  212 
aetiology  of,  213 
diagnosis  of,  213 
pathology  of,  213 
symptoms  of,  213 
treatment  of,  213 
tuberculosis,  184 
Glasgow's  sign,  614 
Gl^nard's  disease,  379 
Glossitis,  336 

chronic  superficial,  336 
Glosso-labio-laryngeal  paralysis,  767 
Glossopharyngeal  nerve,  lesions  of,  806 
Glottis,  oedema  of,  629 
Glycosuria,  265 
Goitre,  exophthalmic,  536 
aetiology  of,  536 
diagnosis  of,  538 
pathology  of,  536 
prognosis  of,  538 
symptoms  of,  537 
Stellwag's  sign,  537 
von  Gr^efe's,  537  ^ 

treatment  of,  539 
serum  in,  540 
simple,  534 
aetiology,  534 


INDEX. 


913 


Goitre,  simple,  pathology,  534 
symptoms  of,  534 
treatment  of,  535 
Gonorrhoeal  arthritis,  142 
diagnosis  of,  143 
pathology  of,  142 
symptoms  of,  143 
treatment  of,  143 
varieties  of,  143 
endocarditis,  142 
infections,  141 

septicaemia  and  pyaemia,  142 
Gout,  256 

aetiology  of,  256 
pathology  of,  259 
pathogenesis  of,  257 
retrocedent  or  metastatic.  261 
symptoms  of,  260 
of  chronic,  261 
of  irregular  or  atypical,  261 
of  typical  acute,  260 
pharyngitis,  260 
treatment  of,  261 
dietetic,  262 
medicinal,  of  acute.  261 
American,  263 
Goutiness,  263 
Gouty  kidney,  696 
Gowers'  sign,  762 
Grain  poisoning,  326 
ergotism,  326 
convulsive,  327 
gangrenous,  326 
lathyrism  or  lupinosis,  328 
pellagra,  327 
treatment  of,  327 
Grand  mal,  822 
Granular  kidney,  692 
Graphospasmus,  849 
Graves'  disease,  536 
Gravel,  711 
Grip,  47 

Grocco's  sign,  660 
Gubler's  sign,  299 
Guinea-worm,  885 
Gull's  disease,  542 

Habit  chorea,  819 

spasm,  819 
Haematemesis,  393 

treatment  of,  365 
Haematochyluria,  884 
Haematoma  of  dura  mater,  726 
Haematoporphyrinuria,  318,  319 
Haematorrhachis,  787 
Haematothorax,  669 
Haematozoon  malariae,  55 
Haematuria,  idiopathic.  719 

symptoms  of,  719 

treatment  of,  720 
Haemoglobinuria,  59,  720 

epidemic,  521 

paroxysmal,  721 

58 


Haemoglobinuria,  toxic,  721 
Hsemopericardium,  556 
Haemophilia,  522 
aetiology  of,  522 
definition  of,  522 
pathology  of,  523 
prognosis  of,  523 
symptoms  of,  523 
treatment  of,  524 
Haemoptysis,  treatment  of,  181 
Haemorrhage,  cerebral,  731 
Haemorrhagic  diseases  of  the  new-born,  521 
treatment  of,  522 
infarct  of  the  bowel,  409 
infarct  of  lung,  205 
syphilis  of  the  newly-born,  521 
Hemorrhoids,  433 
aetiology  of,  434 
definition  of,  433 
pathology  of,  433 
symptoms  of,  434 
external  434 
internal,  434 
treatment  of,  434 
Haemothorax,  669 
Harvest  bug,  893 
Haschisch  poisoning,  322 
symptoms  of,  322 
treatment  of,  322 
Hay  asthma,  621 
Hay-fever,  621 
aetiology  of,  621 
symptoms  of,  621 
treatment  of,  622 
Headache,  bihous,  854 

sick,  854 
Head  louse,  895 

Heart,  albuminoid  degeneration  of,  564 
and  blood-vessels,  diseases  of,  550 
aneurysm  of,  568 
arrhythmia  of,  600 
treatment  of,  603 
atrophy  of,  564 

brown,  564 
block,  600 

chronic  valvular  defects  of,  574 
congenital  defects  of,  586 
dilatation  of,  559 
aetiology  of,  559 
diagnosis  of,  561 
pathology  of,  559 
physical  signs  of,  560 
prognosis  of,  561 
symptoms  of,  560 
treatment  of,  561 
Nauheim  baths,  561 
diseases  of,  550 
exhaustion,  329 
definition  of,  329 
symptoms  of,  329 
treatment  of,  330 
fatty  degeneration  of,  565 
fibroid  degeneration  of,  566 


914 


INDEX. 


Heart,  hypertrophy  of,  556 
murmurs,  table  of,  576 
nervous  palpitation,  598 
diagnosis  of,  599 
treatment  of,  601 
neuroses  of,  598 

parenchymatous  degeneration  of,  564 
rupture  of,  568 
tuberculosis  of,  190 
valvular  disease  of,  574 
Heberden's  nodes,  281 
Hemeralopia,  798 
Hemianopsia,  796 

homonymous,  796 
Hemicrania,  854 

Hepatic  artery  and  vein,  diseases  of,  463 
calculus,  473 
intermittent  fever,  476 
Hepatitis,  acute  parenchymatous,  454 
interstitial,  442 
suppurative,  43  S 
aetiology  of,  438 
diagnosis  of,  440 
pathology  of,  439 
prognosis  of,  441 
symptoms  of,  440 
treatment  of,  441 
Hereditary  ataxia,  766 
ataxic  paraplegia,  766 
aetiology  of,  766 
pathology  of,  766 
prognosis  of,  767 
symptoms  of,  766 
treatment  of,  767 
cerebellar  ataxia,  767 
Hill  diarrhoea,  81 
aetiology  of,  81 
pathology  of,  81 
symptoms  of,  81 
treatment  of,  81 
Hobnail  liver,  442 
Hochsinger's  sign,  730 
Hodgkin's  disease,  529 
Hodgson's  disease,  612 
Hoffmann's  symptom,  834 
Hook-worm  disease,  877 
Hour-glass  stomach,  378 
aetiology  of,  378 
definition  of,  378 
pathology  of,  379 
symptoms  of,  379 
treatment  of,  379 
Huntington's  chorea,  820 
Huchard's  sign,  608 
Hutchinson's  teeth,  149 
Hyaline  degeneration  of  heart,  566 
Hydatid  disease,  887 

of  lungs,  652 
Hydrocephalus,  acute,  729 
aetiology,  729 
diagnosis,  730 
pathology,  729 
prognosis,  730 


Hydrocephalus,  acute,  symptoms,  730 
treatment,  730 
chronic,  730 
aetiology,  730 
pathology,  730 
symptoms,  731 
treatment,  731 
Hydrochloric  acid,  nervous  hypersecretion 

•  of,  3^2 

Hydronephrosis,  707 
aetiology  of,  708 
diagnosis  of,  709 
pathology  of,  708 
prognosis  of,  709 
symptoms  of,  708 
treatment  of,  709 
Hydropericardium,  556 
Hydroperitonaeum,  497 
Hydrophobia,  123 
aetiology  of,  123 
diagnosis  of,  125 
incubation,  124 
Pasteur  treatment,  126 
pathology  of,  123 
prognosis  of,  125 
symptoms  of,  124 
treatment  of,  125 
Hydropneumothorax,  667 
Hydrothorax,  667 
Hymenolopsis  nana,  889 
diminuta,  889 
lanceolata,  890 
Hyperacidity,  gastric,  382 
Hyperaemia  of  the  liver,  463 
active,  463 

treatment,  463 
passive,  464 
£Etiology,  464 
pathology  of,  464 
symptoms  of,  464 
treatment  of,  464 
Hyperchlorhydria,  382 
aetiology  of,  382 
definition  of,  382 
diagnosis  of,  383 
prognosis  of,  383 
symptoms  of,  382 
treatment  of,  383 
diet,  384 
Hyperorexia,  391 
Hyperosmia,  795 
Hypertrophic  pulmonary  osteoarthropathy, 

861 
Hypertrophy  of  heart,  556 
aetiology  of,  557 
diagnosis  of,  558 
pathology  of,  557 
physical  signs  of,  558 
prognosis  of,  558 
symptoms  of,  557 
treatment  of,  55S 
Hypochlorhydria,  385 
diagnosis  of,  3S5 


INDEX. 


915 


Hypochlorhydria,  symptoms  of,  3S5 

treatment  of,  386 
diet  in,  386 
Hypochyiia,  385 
Hypoglossal  nerve,  lesions  of,  813 

a;tiology  of,  813 

symptoms  of,  813 

treatment  of,  814 
Hysteria,  835 

aetiology  of,  835 

prognosis  of,  838 

symptoms  of,  835 

traumatic,  847 

treatment  of,  838 
Hysterical  epilepsy,  836 

fever,  838 

stigmata,  837 

Ichthyotoxismus,  325 
Icterus,  466 

catarrhalis,  466 

gravis,  454 

neonatorum,  471 
Idiopathic  continued  fever,  211 
Ileo-colitis,  acute,  394,  406 
Ileus,  417 

Immunization  against  tuberculosis,  173 
Impacted  gall-stone.  475 
Impulsive  tic,  819 
Indicanuria,  263,  723,  730,  858 

treatment  of,  724 
Indol,  723,  857 
Infantile  convulsions,  831 
ffitiology  of,  831 
diagnosis  of,  831 
prognosis  of,  831 
symptoms  of,  831 
treatment  of,  832 

eclampsia,  831 

palsy,  754 

scurvy,  290 

treatment  of,  291 

spinal  paralysis,  754 
Infarct  of  bowel,  haemorrhagic,  409 

of  lung,  haemorrhagic,  205 
Inflammatory  rheumatism,  114 
Influenza,  47 

aetiology  of,  47 

complications  of,  49 

diagnosis  of,  49 

incubation  of,  48 

pathology  of,  48 

prognosis  of,  49 

symptoms  of,  48 

treatment  of  49 

varieties  of,  48 
Insects,  893 
Insolation,  330 
Insular  sclerosis,  740 
Intermittent  claudication,  608 

fever,  56 

tick  fever,  32 

tetanus,  833 


Internal  capsule,  lesions  of,  748 
Interstitial  nephritis,  chronic,  696 

pneumonia,  chronic,  203 

suppurative  nephritis,  704 
Intestinal  catarrh,  acute,  394 

obstruction,  417 

acute  and  chronic,  417 
definition  of,  417 
diagnosis  of,  417 
symptoms  of,  417,  418,  419,  422 
treatment  of,  422 
Intestine,  embolic  ulcer  of,  412 

primary  tuberculous  ulceration  of,  411 

syphilitic  ulcer  of,  412 
Intestines,  diseases  of,  394 

obstruction  of,  417 

malignant  growths  of,  432 

nervous  affections  of,  429 
Intoxications,    including   the   effects  of  ex- 
posure to  high  temperatures,  299 
Intracranial  tumors,  744 
Intrathoracic  tumors,  670 
Introduction,  i 
Intussusception,  419 

treatment  of,  420 
Invagination,  intestinal,  419 
lodism,  308 

symptoms  of,  308 
Iridoplegia,  792 

accommodative,  793 

reflex,  or  Argyll-Robertson  pupil,  793 

skin,  793 
Irritation  of  auditory  nerve,  798 
Irritative  fever,  210 
Itch  mite,  893 
Ixodiasis,  894 

Jaccoud's  sign,  513 
Jacksonian  epilepsy,  823 
Jail  fever,  33 
Japanese  river  fever,  214 
Jaundice,  466 

acute  catarrhal,  466 
aetiology  of,  466 
definition  of,  466 
diagnosis  of,  46S 
pathology  of,  467 
prognosis  of,  468 
symptoms  of,  467 
treatment  of,  468 
acute  febrile,  212 
epidemic  catarrhal,  212 
malignant,  454 
neonatorum,  471  . 

obstructive,  466 
of  the  new-born,  471 
toxic,  470 

symptoms  of,  470 
Jerkers,  820 
Jigger,  897 
Jumpers,  820 
Justus'  test,  150 
Juvenile  muscular  dystrophy,  867 


9i6 

Kakk6,  206 
Kala-azar,  217 
Kemig's  sign,  107 
Kidney,  abscess  of,  704 
amyloid,  702 

aetiology  of,  702 

diagnosis  of,  703 

duration  of,  703 

pathology  of,  703 

prognosis  of,  703 

symptoms  of,  703 

treatment  of,  704 
anomalies  of  form  and  position,  674 

congenital  absence  of,  674 

floating,  675 

horseshoe,  674 

lobulated,  674 

cirrhotic,  696 
calculi,  711 
carcinoma  of,  716 
congestion  of,  679 

acute,  679 

chronic,  679 
aetiology  of,  679 
diagnosis  of,  680 
pathology  of,  680 
prognosis  of,  680 
symptoms  of,  680 
treatment  of,  680 

passive,  679 
contracted,  696 
cysts  of,  718 

congenital,  718 

dermoid,  718 

differential  diagnosi    of,  719 

echinococcus  or  hydatid,  719 

hydronephrosis,  707 

retention  or  obstruction,  718 

treatment  of,  719 
derangement  of  circulation,  679 
diseases  of,  674 
gouty,  696 
granular,  692 
lardaceous,  702 
large  white,  691 
movable,  675 

aetiology  of,  675 

diagnosis  of,  676 

symptoms  of,  675 

treatment  of,  676 
surgery  in,  677 
sarcoma  of,  716 
sclerotic,  696 
small  white,  692 
stone  in,  711 
surgical,  704 
tuberculosis  of,  188 
tumors  of,  716 

diagnosis  of,  717 

symptoms  of,  717 

treatment  of,  718 
waxy,  702 
Kinepox,  253 


INDEX. 


King's  evil,  184 
Koplik's  spots,  226 
Korsakoff's  disease,  312 
Kreotoxismus,  327 
Kubisagari,  217 

Labyrinthine  vertigo,  805 
Lacquer  poisoning,  324 
symptoms  of,  324 
treatment  of,  325 
Lacunar  tonsillitis,  340 
Laennec's  perles,  630 
La  grippe,  47 
Landry's  paralysis,  768 
Lardaceous  disease  of  the  kidney,  692 

liver,  451 
Large  white  kidney,  691 
Laryngeal  anaesthesia,  809 

muscles,  paralysis  of,  807 
Laryngitis,  acute  catarrhal,  623 
chronic  catarrhal,  624 
aetiology  of,  624 
pathology  of,  624 
symptoms  of,  624 
treatment  of,  625 
spasmodic,  626 
tuberculous,  627 
aetiology  of,  627 
diagnosis  of,  628 
pathology  of,  627 
prognosis  of,  628 
symptoms  of,  628 
treatment  of,  628 
Larynx,  adductor  paralysis  of,  808 
bilateral  abductor  paralysis  of,  808 
diseases  of,  623 
spasm  of,  808 
total  paralysis  of,  808 
unilateral  abductor  paralysis  of,  807 
Latah,  820 
Lateral  sclerosis,  757 

amyotrophic,  759 
Lathy rism,  328 
Lead  poisoning,  297 
acute,  298 
aetiology  of,  297 
chronic,  298 
pathology  of,  297 
prognosis  of,  300 
symptoms  of,  298 

black  line,  298 
treatment  of,  300 
Lennhoff's  sign,  462 
Leontiasis  ossea,  861 
Leprosy,  219 

anaesthetic  form  of,  220 
aetiology,  219 
diagnosis  of,  220 
pathology  of,  219 
prognosis  of,  220 
symptoms  of,  220 
treatment  of,  220 
tubercular,  220 


INDEX. 


917 


Leptomeningitis,  acute,  727 
aetiology  of,  727 
diagnosis  of,  728 
pathology  of,  728 
prognosis  of,  728 
symptoms  of,  728 
treatment  of,  729 
cerebral,  727 
spinal,  783 
acute,  783 
chronic,  784 
Leptus  autumnalis,  893 
Leucaemia,  511 
aetiology  of,  511 
definition  of,  511 
diagnosis  of,  515 
pathology  of,  511 
prognosis  of,  515 
symptoms  of,  512 

blood  changes,  513,  514,  515 
treatment  of,  515 
Leucanaemia,  516 
Leucocythaemia,  511 
Leucoplakia  buccalis,  336 
aetiology  of,  336 
definition  of,  336 
symptoms  of,  336 
treatment  of,  336 
Leucoplasia,  336 
Leucoderma,  863 
Lice,  895 
Lingual  ichthyosis,  336 

psoriasis,  336 
Lingulata  rhinaria,  894 
Lipomatosis  luxurians  muscularis,  866 
Lithaemia,  263 
aetiology  of,  263    ■ 
symptoms  of,  263 
treatment,  263 
Liver,  abnormalities  in  shape  and  position 

of,  435 
abscess  of,  438 
active  hyperaemia  of,  463 
acute  yellow  atrophy  of,  454 
altered  shape  of,  435 
amyloid,  451 
anaemia  of,  463 
cancer  of,  456 
carcinoma  of,  456 

changes  in  hepatic  artery  and  vein,  465 
cirrhosis  of,  442 

aetiology  of,  442 

pathology  of,  443 

prognosis  of,  445 

symptoms  of,  443 

treatment  of,  445 
diseases  of,  435 

blood-vessels  of,  563 
dislocation  of,  435 
echinococcus  disease  of,  460 
fatty,  450 

infiltration  of,  450 

metamorphosis  of,  450 


Liver,  floating,  436 

flukes,  870 

hydatid  cyst  of,  460 

hyperemia  of,  463 

lardaceous,  451 

morbid  growths  of,  456 

movable,  436 

neoplasms  of,  456 

parasites  of,  460 

passive  hyperaemia  of,  464 

sarcoma  of,  457 

syphilis  of,  452 

waxy,  451 
Lobar  pneumonia,  190 
Lobular  pneumonia,  198 
Local  asphyxia,  851 
Localization  of  cerebral  disease,  745 
Lockjaw,  127 
Locomotor  ataxia,  760 

aetiology  of,  760 

pathology  of,  761 

prognosis  of,  763 

symptoms  of,  761 

treatment  of,  763 
Louse,  body,  895 

crab,  896 

head,  895 
Lucas's  sign,  291 
Ludwig's  angina,  338 
Lues  venerea,  145 
Lumbago,  278 
Lumbar  puncture,  108,  109 
Lumpy  jaw,  138 
Lung,  abscess  of,  652 

actinomycosis  of,  136 

blastomycosis  of,  138 

cavities  in,  163 

cirrhosis  of,  203 

diseases  of,  644 

emphysema  of,  644 

fever,  190 

fibroid  induration  of,  203 

gangrene  of,  654 

syphilis  of,  650 

tuberculosis  of,  161 

tumors  of,  651 
carcinoma,  651 

physical  signs,  652 
lymphoma,  652 
sarcoma,  651 
Lupinosis,  328 
Luschka's  lines,  513 
Lymph  scrotum,  884 

vulva,  884 
Lymphadenitis,  tuberculous,  184 
Lymphadenoma,  general,  529 
Lymphadenosis,  529 
Lymphatic  glands,  tuberculosis  of,  184 
Lymphatism,  532 
Lyssa,  123 

Madura  foot,  209 

Maladie  de  la  tic  convulsif,  819 


9i8 


INDEX. 


Malaria,  chronic,  59 
Plasmodium  of,  55 
Malarial  cachexia,  59 
fever,  54 

aestivo-autumnal,  55,  58 
algid  form,  59 
chronic  form,  59 
clinical  chart  of,  57 
clinical  varieties,  56 
comatose  form,  59 
complications  of,  60 
diagnosis  of,  60 
favoring  causes,  54 
geographical  distribution,  54 
hemoglobinuria,  59 
incubation  of,  56 
intermittent  form  of,  56 
irregular  forms  of,  58 
pathology  of,  56 
Plasmodium,  55 
prognosis  of,  60 
prophylaxis  against,  60 
quartan,  55,  56 
quotidian,  56 
remittent  form.  58 
seasons  favoring,  55 
symptoms  of,  56 
tertian,  55,  56 
treatment  of,  60 
Mali-mali,  820 
Malignant  adenitis,  84 
growths  of  intestines,  432 
symptoms  of,  432 
treatment  of,  433 
jaundice,  454 
purpuric  fever,  104 
pustule,  131 
Malleus  humidus,  134 
Malta  fever,  37 
aetiology  of,  38 
distribution  of,  38 
pathology  of,  38 
symptoms  of,  38 
treatment  of,  39 
Mammary  gland,  tuberculosis  of,  190 
Mania-a-potu,  313 
treatment  of,  314 
Marie's  sign,  538 
Marsh  fever,  54 
Maw  worm,  872 
Measles,  225 
retiology  of,  225 
cUnical  chart  of,  226 
complications  and  sequelae  of,  227 
contagiousness  of,  225 
diagnosis  of,  227 
pathology  of,  225 
pneumonia  in,  227 
prognosis  of,  227 
prophylaxis  of,  227 
symptoms  of,  225 
bronchitis,  225 
incubation  period  of,  225 


Measles,  Koplik's  sign,  226 

treatment  of,  227 
Meat  poisoning,  325 
symptoms  of,  325 
treatment  of,  326 
Median  nerve,  lesions  of,  7S7 
Mediastinal  abscess,  672 
disease,     670 
tumors,  670 

diagnosis  of,  671 
pathology  of,  672 
symptoms  of,  670 
treatment  of,  673 
Mediastino-pericarditis,  indurative,  672 
Mediterranean  fever,  37 
Megrim,  85  4 
Melituria,  265 

Membranes  of  the  brain,  diseases  of,  726 
Membranous  croup,  87 
Meniere's  disease,  805 
Meningeal  apoplexy,  785 
Meningitis,  epidemic  cerebrospinal,  104 
spinal,  782 
tuberculous,  729 
aetiology,  729 
diagnosis,  730 
pathology  of,  730 
prognosis,  729 
symptoms,  730 
treatment,  730 
Meningococcus,  105 
Meningoencephalitis,  diffuse,  738 
Menopause,  neurasthenia  of,  844 
Mercurial  poisoning,  301 
acute,  303 

treatment  of,  303 
chronic,  303 

symptoms  of,  304 
treatment  of,  304 
Mercurialism,  303 
Merycism,  388 

treatment  of,  389 
Mesogonimus  heterophyes,  872 
Methyl  alcohol  poisoning,  315 

treatment  of,  316 
Micrococcus  lanceolatus,  191 

melitensis,  38 
Migraine,  854 
aetiology  of,  854 
prognosis  of,  855 
symptoms  of,  854 
treatment  of,  855 
Mild  chorea,  815 
Miliary  fever,  213 
aetiology  of,  213 
diagnosis  of,  214 
duration  of,  214 
pathology  of,  214 
prognosis  of,  214 
symptoms  of,  214 
treatment  of,  214 
Milk  sickness,  140 
Etiology  of,  141 


INDEX. 


919 


Milk  sickness,  diagnosis  of,  141 
pathology  of,  141 
prognosis  of,  141 
symptoms  of,  141 
treatment  of,  141 
Milzbrand,  131 
Mimetic  facial  paralysis,  Soi 

spasm,  803 
Miner's  anaemia,  877 
Mites,  893 

Mitral  insufficiency,  575 
Etiology  of,  575 
diagnosis  of,  577 
mechanism  of,  575 
murmur,  576 
physical  signs,  576 
symptoms  of,  576 
treatment  of,  591 
obstruction,  577 
aetiology  of,  5  78 
diagnosis  of,  579 
mechanism  of,  577 
murmur  in,  5  78 
physical  signs  of,  578 
symptoms  of,  578 
treatment  of,  592 
Monoplegia  facialis,  801 
Morbilli,  225 
Morbus  astralis,  821 
divinus,  821 
maculosus,  518 
neonatorum,  521 
Werlhofii,  520 
sacer,  821 
Morphine  habit,  319 
Morphinism,  319 
prognosis  of,  320 
symptoms  of,  319 
treatment  of,  320 
Morphino mania,  319 
Morphoea,  863 
Morvan's  disease,  771 
Mosquitoes  and  yellow  fever,  42,  45 
Motor  agraphia,  738 
aphasia,  738 

nerves  of  eye,  diseases  of,  798 
Mountain  fever,  29 
Mouth,  and  tongue,  diseases  of,  333 

dry,  337  . . 
Mucous  colitis,  396 
Multiple  arthritis  deformans,  281 

neuritis,  789 

sclerosis  of  brain  and  cord,  740 
Mumps,  97 

aetiology  of,  97 

complications  of,  98 

diagnosis  of,  98 

patliology  of,  97 

prognosis  of,  98 

symptoms  of,  97 

treatment  of,  98 
Murmurs,  heart,  table  of,  576 
Musca  domestica,  894 


Muscular  atrophy  of  peroneal  type,  868 
dystrophy,  juvenile,  867 
of  Landouzy-Dejerine  type,  868 
system,  diseases  of,  865 
Musculospiral  nerve,  neuritis  of,  787 
Myalgia,  278 
Myasthenia  gravis,  857 
Mycetoma,  209 
aetiology  of,  209 
symptoms  of,  209 
treatment  of,  209 
Mycotic  stomatitis,  333 
Myelitis,  diffuse,  acute  and  chronic,  750 
aetiology  of,  751 
pathology  of,  751 
prognosis  of,  753 
symptoms  of,  751 
treatment  of,  753 
acute  anterior  poliomyelitis  of  children, 

754 
aetiology  of,  755 
pathology  of,  755 
prognosis  of,  756 
symptoms  of,  755 
treatment  of,  756 
Myelomalacia,  754 
Myers's  sign,  233 
Myiasis,  894 
Myocarditis,  564 

acute  suppurative,  568 
fatty,  565 
fibrous,  566 
aetiology  of,  566 
diagnosis  of,  567 
patholog}'  of,  566 
physical  signs,  567 
prognosis  of,  567 
symptoms  of,  567 
treatment  of,  567 
interstitial,  566 
parenchymatous,  564 
Myocardium,  diseases  of,  556 
Myositis,  865 
acute,  865 
haemorrhagic,  865 
infectious,  865 
ossifying,  893 
progressiva  ossificans,  866 
suppurative,  865 
Myotonia  congenita,  827 
Myriachit,  820 
Mytilotoxismus,  325 
Myxoedema,  541 
aetiology  of,  541 
diagnosis  of,  543 
pathology  of  542 
prognosis  of,  543 
symptoms  of,  542 
treatment  of,  543 

Nakra  fever,  63 
Nasa  fever,  63 
Nasha  fever,  63 


920 


INDEX. 


Nauheim  treatment,  561 
Neapolitan  fever,  37 
Nemathelminthes,  872 
Nematodes,  or  round  worms,  872 
Neoplasmata  cerebri,  744 
Neoplasms  of  peritonaeum,  497 
of  kidney,  716 
of  lungs,  652 
of  thyroid  gland,  545 
Nephritis,  acute,  684 
aetiology  of,  684 

complications  of,  686 
pneumonia,  686 
diagnosis  of,  686 
pathology  of,  685 

glomerular  changes,  685 
interstitial  changes,  685 
tubal  changes,  685 
prognosis  of,  687 
symptoms  of,  685 

urine,  686 
treatment  of,  687 
chronic  arterial,  696 
aetiology  of,  696 
complications  of,  699 
diagnosis  of,  699 
pathology  of,  697 
prognosis  of,  700 
symptoms  of,  698 
cardiac,  699 

hypertrophy  of  the  left  ventricle,  699 
urine,  688 
treatment  of,  700 
chronic  haemorrhagic,  696 
chronic  interstitial,  696 
chronic  parenchymatous,  691 
Etiology  of,  691 
diagnosis  of,  693 
pathology  of,  691 
prognosis  of,  693 
symptoms  of,  692 
duration  of,  693 
urine,  693 
treatment  of,  693 
diet,  694 

dechloridation  in,  694 
septic  and  pyaemic,  704 
suppurative  interstitial,  704 
aetiology  of,  704 
diagnosis  of,  706 
pathology  of,  705 
prognosis  of,  706 
symptoms  of,  705 

urine,  706 
treatment  of,  707 
Nephrolithiasis,  711 
aetiology  of,  711 
diagnosis  of,  713 

Rontgen  ray  in,  714 
pathology  of,  712 
prognosis  of,  714 
symptoms  of,  712 
treatment  of,  714 


Nephroptosis,  675 
Nephrydrosis,  707 

Nerve,  circumflex,  affections  of,  781 
median,  781 
musculospiral,  781 
treatment  of  lesions  of,  782 
ulnar,  781 
Nerves,  peripheral,  diseases  involving,  780 
Nervous  affections  of  intestines,  429 

treatment  of,  430 
Nervous  deafness,  799 
symptoms  of,  799 
treatment  of,  799 
eructation  of  gas,  389 
exhaustion,  840 
fever,  7 

hypersecretion  of  hydrochloric  acid,  382 
prostration,  840 
system,  diseases  of,  725 
functional  diseases  of,  814 
Neuralgia,  see  migraine,  854 
Neurasthenia,  840 
aetiology  of,  S40 
prognosis  of,  840 

symptoms  of,  840  '' 

treatment  of,  841 
Neurasthenia  of  the  menopause,  844 
symptoms  of,  844 
treatment  of,  845 
Neuritis,  786 
localized,  786 
aetiology,  786 
pathology  of,  786 
symptoms  of,  787 
treatment  of,  788 
multiple,  peripheral,  789 
aetiology  of,  789 
pathology  of,  789 
prognosis  of,  791 
symptoms  of,  789 
treatment  of,  791 
Neuroses  of  the  stomach,  382 
occupation,  848 
of  heart,  604 
of  intestines,  429 
traumatic,  847 
New-born,  haemorrhagic  diseases  of,  531 

syphilitic  diseases  of,  521 
Ninth  nerve,  lesions  of,  806 
Noma,  334 

Nose,  diseases  of,  620 
Nyctalopia,  798 
Nystagmus,  799 

Obesity,  284 

aetiology  of,  284 

definition  of,  284 

diets  in,  285 

symptoms  of,  284 

treatment  of,  285 
Obstruction  of  bowel,  417 
Occupation  neuroses,  848 

aetiology  of,  849 


INDEX. 


921 


Occupation  neuroses,  pathology  of,  849 
prognosis  of,  849 
symptoms  of,  849 
treatment  of,  850 
Ocular  palsy,  799 

treatment  of,  800 
CEdema,  angioneurotic,  853 
(Edema  of  glottis,  630 

treatment  of,  631 
CEsophagismus,  344 
CEsophagitis,  acute,  343 
Etiology  of,  343 
definition  of,  343 
pathology  of,  343 
symptoms  of,  343 
treatment  of,  343 
chronic  catarrhal,  344 
(Esophagus,  benign  stricture  of,  345 
aetiology  of,  345 
symptoms  of,  345 
treatment  of,  345 
cancer  of,  344 
symptoms  of,  345 
treatment  of,  345 
dilatations  of,  346 
symptoms  of,  346 
treatment  of,  346 
diseases  of,  343 
spasm  of,  344 
aetiology  of,  344 
symptoms  of,  344 
treatment  of,  344 
Oculomotor  nerve,  diseases  of,  798 
Olfactory  nerves,  diseases  of,  794 
Onomatomania,  819 
Ophthalmoplegia,  799 
Open-air  treatment  in  tuberculosis,  175 
Opium  poisoning,  see  morphinism,  319 
Oppler-Boas  bacillus,  370,  376 
Opsonic  therapy  in  tuberculosis,  183 
Optic  atrophy,  796 
gray,  796 
haemorrhage,  797 
nerve  affections,  795 

and  tract,  795 
neuritis,  796 
aetiology  of,  796 
pathology  of,  796 
symptoms  of,  796 
Osteitis  deformans,  861 
Osteo-arthritis,  280 
Osteo-arthropathy,  861 
Ovaries,  tuberculosis  of,  189 
Oxyuris  vermicularis,  874 

Pachymeningitis,  726 
external,  726 
haemorrhagic,  726 
internal,  726 
pseudo-membranous,  727 
purulent,  727 
spinal,  782 

cervical  hypertrophic,  78a 


Pachymeningitis,  spinal,  external,  782 
haemorrhagic,  783 
internal,  782 
Paget's  disease,  861 
Painter's  palsy,  299 
Palpitation  of  heart,  598 
Paludal  fever,  54 
Pancreas,  cancer  of,  487 
diagnosis  of,  487 
morbid  anatomy  of,  487 
symptoms  of,  487 
cysts  of,  488 
diseases  of,  483 
Pancreatic  abscess,  484 

calculi,  489 
Pancreatitis,  acute,  483 
definition  of,  483 
acute  gangrenous,  485 
acute  haemorrhagic,  484 
acute  suppurative,  484 
chronic,  486 
Papillitis,  796 
Parageusia,  807 
Paralysis,  acute  ascending,  766 
aetiology  of,  767 
pathology  of,  767 
prognosis  of,  767 
symptoms  of,  767 
treatment  of,  767 
agitans,  829 
aetiology  of,  829 
pathology  of,  829 
prognosis  of,  830 
symptoms  of,  830 
treatment  of,  831 
bulbar,  767 
general,  738 
aetiology,  739 
pathology,  739 
prognosis,  740 
symptoms,  739 
treatment,  740 
glosso-labio-laryngeal,  767 
Landry's,  768 
of  the  tongue,  the  soft  palate,  and  lips, 

767 
periodical,  85  S 
pseudo-hypertrophic,  866 
Paramyoclonus,  multiplex,  828 
aetiology  of,  828 
symptoms  of,  829 
treatment  of,  829 
Paranephritis,  710 
aetiology  of,  710 
diagnosis  of,  711 
pathology  of,  710 
symptoms  of,  711 
treatment  of,  711 
Paraplegia,  ataxic,  770 
aetiology  of,  770 
pathology  of,  770 
prognosis  of,  771 
symptoms  of,  770 


922 


INDEX. 


Paraplegia,  ataxic,  treatment  of,  771 

spastic,  761 
Parasites,  animal,  869 

of  the  liver,  460 
Parasitic  diseases,  869 
flies,  894 
insects,  893 
Paratyphoid  fever,  28 
Parenchymatous  degeneration  of  heart,  564 

myocarditis,  564 
Paresis,  general,  73S 
Paretic  dementia,  738 
Parkinson's  disease..  829 
Parosmia,  795 
Parotitis,  acute,  337 
treatment  of,  338 
epidemic,  97 
secondary,  337 
Parrot's  sign,  149,  830 
Parry's  disease,  536 

Pasteur's  treatment  of  hydrophobia,  126 
Pediculosis,  895 
Pediculus  capitis,  895 
vestimentorum,  895 
pubis,  896 
Peliosis,  518 

rheumatica,  519 
Pellagra,  327 

prognosis  of,  328 
symptoms  of,  328 
treatment  of,  328 
Pentastomum  constrictum,  894 
denticulatum,  463 
ta;nioides,  463,  894 
Peptic  ulcer,  358 
Perez's  sign,  671 
Pericarditis,  550 
acute,  550 

jetiology  of,  550 
definition  of,  550 
diagnosis  of,  552 
pathology  of,  550 
physical  signs,  551 
Broadbent's  sign,  555 
Friedreich's  sign,  555 
of  chronic  adhesive,  555 
pleuropericardial  friction  sound,  553 
Rotch's  sign,  552 
prognosis  of,  553 
svmptoms  of,  551 
treatment  of,  553 
chronic  adhesive,  555 
symptoms  of,  555 
treatment  of,  555 
Pericardium,  adherent,  555 
calcification  of,  556 
cancer  of,  556 
diseases  of,  550 
paracentesis  of,  554 
tuberculosis  of,  1S7 
Perihepatitis,  437 
aetiology  of,  437 
definition  of,  437 


Perihepatitis,  diagnosis  of,  437 
pathology  of,  437 
prognosis  of,  438 
symptoms  of,  437 
treatment  of,  438 
Perinephric  abscess,  710 
Perinephritis,  710 
Periodical  paralysis,  858 
Peripheral  nerves,  affections  of,  786 

neuritis,  789 
Perisplenitis,  526 
Peristaltic  unrest,  388 
Peritonaeum,  cancer  of,  496 
diseases  of,  489 
neoplasms  of,  496 
tuberculosis  of,  186 
Peritonitis,  acute,  4S9 
aetiology  of,  489 
definition  of,  489 
diagnosis  of,  492 
pathology  of,  490 
physical  signs,  491 
prognosis  of,  493 
symptoms  of,  491 
treatment  of,  493 

of  acute  general,  493 
chronic,  493 
circumscribed,  495 
difl'use,  495 
hysterical,  492 
in  typhoid  fever,  13 
tuberculosis,  1S4 
Peritonsillar  abscess,  342 
Perityphlitis,  412 
Pernicious  anaemia,  507 
malarial  fever,  59 
algid  type,  59 
comatose  type,  59 
haemorrhagic  type,  59 
temperature,  59 
treatment  of,  62 
Pertussis,  99 
Peruvian  warts,  223 
Pest,  the,  84 
Pestis  major,  85 

minor,  84 
Pestilential  or  putrid  fever,  33 
Petechial  fever,  104 
Petit  mal,  823 

Pharyngitis,  acute  catarrhal,  338 
aetiology  of,  338 
definition  of,  338 
pathology  of,  339 
symptoms  of,  339 
treatment  of,  339 
Pharynx,  diseases  of,  338 
Phthisis,  acute,  161 

broncho-pneumonic,  161 
chronic  ulcerative,  162 
fibroid,  169 

physical  signs  of,  169 
symptoms  of,  169 
florida,  161 


INDEX. 


923 


Phthisis,  pneumonic  form  of,  161 

pulmonalis,  161 
Piles,  433 
Pin  worm,  S74 
Pityriasis  of  tongue,  335 
Plague,  bubonic,  84 
Plasmodium  malance,  55 
Plathelminthes,  870,  8S7 
cestodes,  887 
trematodes,  870 
blood  Quke,  871 
liver  fluke,  870 
lung  fluke,  870 
Pleura,  diseases  of,  656 
hydatid  disease,  670 
neoplasms  of,  669 
carcinoma,  669 

enchondroma  and  lipoma,  670 
sarcoma,  669 
tuberculosis  of,  1S6 
Pleurisy,  656 

acute,  fibrinous,  656 
aetiology  of,  656 
pathology  of,  656 
physical  signs  of,  656 
prognosis  of,  656 
symptoms  of,  656 
treatment  of,  657 
chronic  adhesive,  666 
aetiology,  666 
pathology,  666 
physical  signs,  666 
symptoms,  666 
treatment,  666 
diaphragmatic,  657 
dry,  656 
exudative,  658 
haemorrhagic,  669 
purulent,  663 
serous,  658 

aetiology  of,  658 
pathology  of,  658 
physical  signs  of,  659 
symptoms  of,  659 
treatment  of,  660 
tapping,  661 
thoracocentesis  in,  661 
suppurative,  663 
tuberculous,  1S4 
Pleuritis,  656 
Pleurodynia,  279 
Plumbism,  297 

Pneumogastric  nerve,  lesions  of,  807 
cardiac  branches  of  the,  809 
aetiology  of,  809 
diagnosis  of,  809 
gastric  and  oesophageal  branches  of  the, 

809 
involving  the  nucleus  and  trunk,  807 
laryngeal  branches  of  the,  807 

symptoms  of,  808 
pharyngeal  branches  of  the,  807 
aetiology  of,  807 


Pneumogastric  nerve,  symptoms  of,  S07 
pulmonary  branches  of  the,  809 
treatment  of,  810 
Pneumonia,  acute  infectious,  190 

aetiology  of,  190 

bacillus  of,  190,  191 

clinical  chart  of,  192 

complications  of,  194 

diagnosis  of,  195 

pathology  of,  191 

physical  signs  of,  193 

prognosis  of,  195 

prophylaxis  of,  195 

treatment  of,  195 
broncho-,  198 

aetiology  of,  198 

diagnosis  of,  200 

pathology  of,  199 

physical  signs,  200 

prognosis  of,  201 

symptoms  of,  199 

treatment  of,  201 
catarrhal,  198 
chronic  interstitial,  203 

aetiology  of,  203 

diagnosis  of,  204 

pathology  of,  203 

physical  signs  of,  204 

prognosis  of,  204 

symptoms  of,  204 

treatment  of,  204 
croupous,  190 
embolic,  205 

non-septic,  205 

septic,  206 
fibrinous,  190 
foreign-body,  198 
herpes  in,  193 
inhalation,  196 
interstitial,  203 
lobar.  190 
lobular,  198 

prune-juice  expectoration,  193 
syphilitic,  650 
Pneumonic  phthisis,  161 
Pneumonitis,  190 
Pneumopericardium,  556 
Pneumothorax,  667 
aetiology  of,  667 
diagnosis  of,  668 
physical  signs  of,  668 

Hippocratic  succussion,  668 

metallic  tinkling,  668 
symptoms  of,  668 
treatment  of,  668 
Podagra,  256 
Poliomyelitis,  acute  anterior,  754 

aetiology  of,  755 

pathology  of,  755 

prognosis  of,  756 

symptoms  of,  755 

treatment  of,  756 
chronic  anterior,  757 


924 


INDEX. 


Poliomyelitis,    chronic   anterior,    pathology 

of,  757 

symptoms  of,  757 

treatment  of,  757 
Pollen  catarrh,  621 
Polycythsemia,  517 
Polymyositis  hcemorrhagica,  865 
Polyneuritis,  789 
Porencephalus  constrictus,  894 
Portal  vein,  thrombosis  and  embolism  of, 

465 
Posterior  spinal  sclerosis,  760 
Pox,  145 

Presystolic  murmur,  578 
Primary  lateral  sclerosis,  757 
Proctitis,  433 

epidemic  gangrenous,  80 

aetiology  of,  80 

pathology  of,  80 

symptoms  of,  80 

treatment  of,  80 
Professional  spasm,  848 
Progressive  bulbar  palsy,  767 

aetiology  of,  767 

pathology  of,  768 

prognosis  of,  768 

symptoms  of,  768 

treatment  of,  768 
facial  hemiatrophy,  856 
general  paralysis  of  the  insane,  738 
muscular  atrophy,  type  Duchenne-Aran, 

.  .757 
pernicious  anaemia,  507 
spastic  paraplegia,  757 
spinal  muscular  atrophy,  757 
aetiology  of,  757 
pathology  of,  757 
prognosis  of,  757 
symptoms  of,  757 
treatment  of,  757 
Prostate  gland,  tuberculosis  of,  189 
Protracted  idiopathic  continued  fever,  211 
aetiology  of,  211 
symptoms  of,  211 
treatment  of,  211 
Prune-juice  expectoration,  193 
Pseudo-angina,  604 
Pseudo-hypertrophic  paralysis,  866 
Pseudo-hypertrophy  of  muscles,  866 
Pseudo-Ieucasmia,  529 
aetiology  of,  529 
definition  of,  529 
diagnosis  of,  531 
pathology  of,  530 
prognosis  of,  531 
symptoms  of,  530 
treatment  of  531 
splenic,  528 
Pseudo-membranous  croup,  626 

enteritis,  408 
Psilosis,  82 
Psorospermiasis,  869 
Psychical  epilepsy,  823 


Psychical  epileptic  equivalent,  823 
Psychosis  polyneuritica,  312 
Ptomaine  poisoning,  325 

treatment  of,  326 
Ptosis,  799 
Ptyalism,  337 

treatment  of,  337 
Puerperal  eclampsia,  832 
Pulex  irritans,  8g6 

penetrans,  897 
Pulmonary  abscess,  652 

consumption,  162 

emphysema,  644 

syphilis,  650 
Pulmonic  insufl&ciency,  585 

obstruction,  585 
Pulse,  irregular,  600 

delirium  cordis,  601 

embryocardial,  601 

explanation  of,  601 

gallop  rhythm,  600 

peculiarities  of,  600 

varieties  of,  600 
Pulsus  bigeminus,  600 

paradoxus,  551,  555,  600 

trigeminus,  600 
Purinaemia,  263 

aetiology  of,  263 

definition  of,  263 

diet  in,  263 

symptoms  of,  263 

treatment  of,  263 
Purpura,  518 

arthritic,  519 

treatment  of,  520 

fulminans,  520 

haemorrhagica,  520 
treatment  of,  520 

Henoch's,  519 

simple  arthritic,  519 
Putrid  sore  throat,  87 
Pyaemia,  120 

aetiology  of,  120 

diagnosis  of,  121 

prognosis  of,  122 

symptoms  of,  121 

treatment  of,  122 
Pyelitis,  704 
Pyelonephrosis,  704 
Pylephlebitis,  465 
Pylethrombosis,  465 
Pylorospasm,  387 

treatment  of,  387 
Pylorus,  hypertrophic  stenosis  of,  373 

Etiology  of,  373 

definition  of,  373 

pathology  of,  373 

symptoms  of,  373 

treatment  of,  373 
Pyothorax,  663 
Pyopneumothorax,  667 
Pyroplasma  hominis,  29 
Pyrosoma  bigeminum,  29 


INDEX. 


925 


Quincke's  lumbar  puncture,  108,  109 

sign,  581 
Quinsy  sore  throat,  342 

aetiology  of,  342 

definition  of,  342 

pathology  of,  342 

symptoms  of,  342 

treatment  of,  342 

Rabies,  123 
Rachitis,  291 
Rag-picker's  disease,  133 
Railway  brain,  847 

spine,  847 
Raynaud's  disease,  851 

aetiology  of,  851 

pathology  of,  851 

prognosis  of,  852 

symptoms  of,  85 1 

treatment  of,  852 
Reaction  of  degeneration,  755 
Rectum,  cancer  of,  432 
Recurrent  typhus,  39 
Reichmann's  disease,  382 
Relapsing  fever,  39 

aetiology  of,  39 

clinical  chart  of,  40 

incubation  in,  40 

pathology  of,  40 

prognosis  of,  41 

relapse  in,  41 

spleen  in,  40 

symptoms  of,  40 

treatment  of,  41 
Remittent  fever,  58 

chill  in,  58 

diagnosis  of,  60 

prodromal  symptoms  of,  58 

treatment  of,  62 
Renal  cirrhosis,  696 

cohc,  713 

dropsy,  692 

epis taxis,  719 

haemorrhage,  719 

sand,  712 

sclerosis,  696 

stone,  711 
Ren  mobilis,  675 

Respiratory  system,  diseases  of,  620 
Retina,  affections  of,  797 

functional  disturbances  of,  798 

haemorrhage  into,  797 

hyperaesthesia  of,  798 

organic  disease  of,  797 
Retinal  haemorrhage,  797 
Retinitis,  797 

nephritic,  693,  797 

pigmentosa,  797 

syphilitic,  797 
Re-vaccination.  255 
Rhachitis,  291 
Rheumatic  fever,  114 

purpura,  115 


Rheumatism,  acute  articular,  1 14 
aetiology  of,  114 
clinical  chart  of,  116 
complications  of,  116 
pathology  of,  115 
prodrome,  115 
prognosis  of,  117 
recurrence,  116 
symptoms  of,  115 
treatment  of,  115 
chronic,  276 
aetiology  of,  276 
definition  of,  276 
pathology  of,  276 
symptoms  of,  276 
treatment  of,  276 
muscular,  278 
aetiology  of,  278 
definition  of,  278 
diagnosis  of,  278 
symptoms  of,  278 
cephalodynia,  279 
lumbago,  278 
pleurodynia,  279 
stiff  neck  or  torticollis,  278 
treatment  of,  279 
Rheumatoid  arthritis,  280 
Rhinitis,  acute,  620 
symptoms  of,  620 
treatment  of,  620 
vaso-motor,  621 
Rickets,  291 

aetiology  of,  29 1 
definition  of,  291 
diagnosis  of,  204 
shape  of  chest,  292 
pathology  of,  292 
prognosis  of,  294 
symptoms  of,  293 
treatment  of,  294 
Rock  fever,  37 
Rocky  Mountain  fever,  29 
Romberg's  symptom,  762 
Room  disinfection,  247 
Rose  cold,  621 
Roseola,  229 
Rotch's  sign,  552 
Rotheln,  229 
Round  worm,  872 
Rubella,  229 
aetiology  of,  230 
diagnosis  of,  230 
incubation  of,  230 
prognosis  of,  231 
symptoms  of,  230 
treatment  of,  231 
Rubeola,  225 
Rumination,  388 
Rumpf's  sign,  848 

Salicyluric  acid  in  urine,  118 

test  for,  118 
Salivary  glands,  diseases  of,  337 


926 


INDEX. 


Salivary  glands,  inflammation  of,  337 
Sanatorium  treatment  in  tuberculosis,  175 
Sand  flea,  897 
Sarcoma  of  the  liver,  457 

of  lung,  651 
Sarcophila  carnaria,  894 
Sarcoptes  scabiaei,  S93 
Saturnism,  297 
Scanning  speech,  766 
Scarlatina,  231 
aetiology  of,  231 
clinical  chart  of,  234 
complications  and  sequelae,  234 
diagnosis  of,  235 
haemorrhagic,  234 
maligna,  234 
miliaris,  233 
pathology  of,  232 
prognosis  of,  236 
prophylaxis  of,  236 
scarlatina  anginosa,  234 
symptoms  of,  232 

raspberry  tongue,  233 
strawberry  tongue,  233 
treatment  of,  236 
Scarlet  fever,  231 
Schistosomum  Cattoi,  872 

haematobium,  871  • 

Schott  treatment,  561 
Sciatica,  792 
aetiology  of,  792 
prognosis  of,  793 
symptoms  of,  792 
treatment  of,  793 
Sclerodactyly,  863 
Scleroderma,  862 
Sclerose  en  plaques,  740 
Sclerosis,  amyotrophic  lateral,  759 
aetiology  of,  759 
pathology  of,  759 
symptoms  of,  759 
treatment  of,  760 
disseminated,  740 
insular,  740 
lateral,  757 
multiple,  740 
of  coronary  arteries,  604 
of  hver,  442 
Scorbutus,  287 
Scotoma,  798 
Scrivener's  palsy,  849 
Scrofula,  184 
Scurvy,  287 

aetiology  of,  287 
definition  of,  287 
diagnosis  of,  289 
prognosis  of,  289 
symptoms  of,  288 
treatment  of,  289 
infantile,  290 
aetiology  of,  290 
definition  of,  290 
diagnosis  of,  290 


Scurvy,  infantile,  pathology  of,  290 
prognosis  of,  291 
symptoms  of,  290 
treatment  of,  291 
Seat-worm,  874 
Seguin's  sign,  823 

Seminal  vesicles,  tuberculosis  of,  i8< 
Septicaemia,  120 
aetiology,  120 
and  pyaemia,  120 
bacilli,  120 
diagnosis  of,  121 
prognosis  of,  122 
symptoms  of,  121 
treatment  of,  122 
Serum,  Trunecek's,  609 
Seven-day  fever,  39 
Seventh  nerve,  lesions  of,  801 
Shaking  palsy,  829 
Shell-fish  poisoning,  325 
Shiga's  bacillus,  402 
Ship  fever,  7,2 
Sick  headache,  854 
Sign,  Abadie's,  537 
Auenbrugger's,  552 
Bacelli's,  660 
Beaume's,  604 
Bechterew's,  762 
Behier-Hardy's,  655 
Berger's,  762 
Boas's,  376 
Bordier-Frankel's,  S02 
Boutillau's,  5 58 
Bouveret's,  422 
Brach-Romberg's,  762 
Burton's,  298 
Cardarelli's,  616 
Charcot's,  608 
Chovostek's,  834 
Clark's,  492 
Dance's,  420 
De  Mussey's,  657 
Drummond's,  614 
Ewart's,  552 
Flush -tank,  711 
Frankel's,  762 
Glasgow's,  614 
Gowers's,  762 
Grocco's,  660 
Gubler's,  299 
Hochsinger's,  730 
Hoffmann's,  834 
Huchard's,  608 
Jaccoud's,  513 
Lennhoff's,  462 
Lucas's,  291 
Marie's,  538 
Myers's,  233 
Parrot's,  149,  830 
Perez's,  671 
Quincke's,  581 
Romberg's,  762  _ 
Rumpf's,  848 


INDEX. 


927 


Sign,  Seguin's,  S23 

Skoda's,  660 

Stellwag's,  537 

Sliller's,  3S0 

Trousseau's,  834 

Unschald's,  267 

Von  Grsefe's,  537 

Wahl's,  418 

Westphal's,  761 

Wintrich's,  168 
Simple  continued  fever,  211 

or  round  ulcer,  35S 
Sinuses  of  brain,  thrombosis  of,  737 
Siriasis,  330 

Sixth  nerve,  lesions  of,  affecting  the  eye- 
ball, 799 
Skoda's  sign,  660 
Slows,  140 
Sleeping-sickness,  217 

pathology  of,  217 

symptoms  of,  217 

treatment  of,  217 
Smallpox,  242 

ffitiology  of,  242 

clinical  chart  of,  244 

complications  of,  246 

contagium  of,  242 

diagnosis  of,  246 

forms  of,  243 
confluent,  245 
discrete,  243 
hasmorrhagic,  245 

purpura  variolosa,  245 
variola  hsemorrhagica  pustulosa,  2^5 
variola;  sine  variolis,  246 
varioloid,  246 

pathology  of,  242 

prognosis  of,  247 

prophylaxis  of,  247 

symptoms  of,  243 
incubation,  243 
initial  rashes,  244 

diffuse  scarlatinous,  244 
muscular  pain   243 

treatment  of,  247 
Smoker's  tongue,  336 
Sore  throat,  338 
Spasm  of  larynx,  catarrhal,  626 
Spasmodic  croup,  626 

tabes  dorsalis,  757 
Spastic  paraplegia,  757 

aetiology,  758 

pathology  of,  758 

symptoms  of,  758 

treatment  of,  759 
Spastic  spinal  paralysis,  757 

aetiology,  758 

pathology  of,  738 

prognosis  of,  758 

symptoms  of,  758 

treatment  of,  759 
Speech,  derangements  of,  73S 
Spinal  accessory  nerve,  lesions  of,  810 


Spinal  accessory  nerve,  symptoms  of,  Sii, 

8l2 

spasm  of,  812 
treatment  of,  812 
cord,  acute  affections  of,  750 
and  meninges,  tumors  of,  780 
symptoms  of,  780 
treatment  of,  781 
compiession  of,  7 78 
aetiology  of,  778 
pathology  of,  778 
prognosis  of,  779 
symptoms  of,  778 
treatment  of,  778 
diseases  involving  the,  750 
haemorrhage  into  the  substance  of,  772 
membranes,  haemorrhage  into,  7S5 
extra-meningeal,  7S5 
intra-meningeal,  785 
treatment,  786 
meningitis,  782 
tumors  of,  7 So 
paralysis  of  children,  754 
Spine,  railway,  847 
Spirillum  fever,  39 
Spirochseta  of  Obermeier,  39 
pallida,  145 
refringens,  145 
Splanchnoptosis,  379 
Spleen,  abscess  of,  526 
amyloid,  527 
diseases  of,  525 
echinococcus,  528 
in  anthrax,  133 
in  cirrhosis  of  the  liver,  444 
in  leucaemia,  512 
in  malaria,  56 
in  typhoid  fever,  8 
in  typhus  fever,  34 
neoplasms  of,  527 
rupture  of,  527 
wandering,  525 
Splenic  anaemia,  528 

pseudo-leucaemia,  528 
apoplexy,  131 
fever,  131 
Splenitis,  526 

Splenomegaly,  tropical,  217 
Spondylitis  deformans,  282 
Sporozoa,  869 
Spotted  fever,  29,  104 
Sprue,  82 

aetiology  of,  82 

pathology  of,  82 

symptoms  of,  82 

treatment  of,  83 

Sputum,  tuberculous,  155 

St.  Anthony's  fire,  in 

Status  epilepticus,  823 

lymphaticus,  532 
Stegomyia  fasciata,  42 
Stellwag's  sign,  537 
Stenocardia,  603 


928 


INDEX. 


Stenosis,  hypertrophic,  of  pylorus,  373 
Stigmata,  hysterical,  837 
Stiller's  sign,  380 
Stokes-Adams  syndrome,  600 
Stomach,  acute  dilatation  of,  377 
bilocular,  378 
cancer  of,  369 
aetiology  of,  369 
diagnosis  of,  370 
pathology  of,  369 
prognosis  of,  371 
stomach  contents  in,  370 
symptoms  of,  369 
treatment  of,  371 
surgery  in,  372 
chronic  catarrh  of,  350 
dilatation  of  the,  374 
aetiology  of,  374 
definition  of,  374 
diagnosis  of,  375 
pathology  of,  374 
physical  signs  of,  375 
stomach  contents  in,  376 
symptoms  of,  374 
treatment  of,  376 
dietetic,  377 
surgery  in,  377 
diseases  of,  347 
hour-glass,  378 
neuroses  of,  382 
ulcer  of,  358 
Stomatitis,  ^^$ 
aphthous,  139 
epidemic,  139 
gangrenous,  334 
aetiology  of,  334 
definition  of,  334 
pathology  of,  334 
symptoms  of,  334 
treatment  of,  335 
mycotic,  3^3 
prophylaxis  against,  333 
treatment  of  different  forms  of,  333 
Stone,  kidney,  711 
Strangulation  of  intestine,  418 
Strongyloides  intestinalis,  876 
Struma  exophthalmica,  536 

simple,  534 
St.  Vitus'  dance,  814 
Sulphonethylmethane  poisoning,  318 
symptoms  of,  318 
treatment  of,  318 
Sulphonal  poisoning,  318 
Sulphonmethane  poisoning,  318 
symptoms  of,  318 
treatment  of,  31S 
Sunstroke,  330 
aetiology  of,  330 
definition  of,  330 
pathology  of,  330 
prognosis  of,  331 
symptoms  of,  330 
treatment  of,  331 


Suprarenal  capsule,  diseases  of,  547 
Surgical  kidney,  704 
Swamp  fever,  54 
Swelled  head,  136 
Sydenham's  chorea,  814 
Symmetrical  gangrene  of  extremities,  851 
Syphilis,  145 
acquired,  147 
aetiology  of,  145 
diagnosis  of,  150 
initial  sore,  147 
pathology  of,  147 

condyloma  acuminatum,  148 

latum,  147 
gumma,  148 

treatment  of,  150 
mucous  patch,  147 
papular  eruption,  147 
pustular  eruption,  147 
syphilides,  147 
macular,  147 
squamous,  147 
venereal  wart,  148 
primary,  147 
secondary,  147 
symptoms  of,  148 
tertiary,  148 
hereditary,  146,  149 
germ  infection,  146 
Hutchinson's  teeth,  149 
sperm  infection,  146 
transmission,  146 
treatment  of,  144 
of  the  liver,  452 
diagnosis  of,  453 
symptoms  of,  453 
treatment  of,  453 
of  lungs,  650 

of  the  newly-born,  haemorrhagic,  521 
pulmonary,  650 
Syphilitic  ulcer  of  bowel,  412 
Syringomyelia,  770 
aetiology  of,  770 
pathology  of,  770 
prognosis  of,  771 
symptoms  of,  770 
treatment  of,  771 

Tabes  dorsalis,  760 
aetiology  of,  760 
course  of,  761 
pathology  of,  761 
prognosis  of,  763 
symptoms  of,  761 

arthropathies,  762 

crises  in,  762 

gait,  762 

girdle  pains,  761 

incoordination,  762 

motor  phenomena,  762 

reflex,  76 r,  762,  763 

Romberg's  sign,  762 

sensory,  762 


INDEX. 


929 


Tabes  dorsalis,   symptoms  of,   vaso-motor 
and  trophic  phenomena  762 
visceral  pain,  762 
treatment  of,  763 

mesenterica,  186 
Tabetic  crises,  762 
Table  of  heart  murmurs,  576 
Tachycardia,  599 

explanation  of,  599 

paroxysmal,  599 

strumosa,  536 

treatment  of,  601 
Taenia,  887 

Africana,  890 

canina,  889 

confusa   890 

cucumerina,  889 

echinococcus,  887 

eliptica,  889 

fiavopuncta,  889 

lanceolata,  890 

lata,  888 

Madagascariensis,  890 

marginata,  890 

mediocanellata,  887 

nana,  889 

saginata,  887 

solium,  888 
Tape-worms,  887 

beef,  8S7 

dog,  889 

fish,  888 

pork.  888 

treatment  of,  891 
Temperature,  efifects  of  high,  329 
Tent  life  for  the  tuberculous,  176 
Tenth  nerve,  lesions  of,  797 
Testicles,  tuberculosis  of,  189 
Tetanilla,  833 
Tetanus,  127 

aetiology  of,  127 

bacillus  of,  127 

diagnosis  of,  129 

head,  128 

pathology  of,  128 

predisposing  causes  of,  128 

prognosis  of,  129 

symptoms  of,  128 

treatment  of,  129 
antitoxin  in,  129 

varieties  of,  128 
idiopathic,  128 
neonatorum,  128 
traumatic,  128 
Tetany,  833 

aetiology  of,  833 

pathology  of,  834 

prognosis  of,  834 

symptoms  of,  834 

treatment  of,  834 
The  pox,  145 
Thermic  lever,  330 

treatment  of,  331 

59 


Third  nerve,  lesions  of,  798 
Thomsen's  disease,  827 
Thoracocentesis,  technique  of,  661 
Thornhead  worms,  877 
Thread  worms,  874 

Thrombosis  and  embolism,  of  cerebral  ar- 
teries, 735 

of  venous  sinuses  of  brain,  737 
primary.  737 
secondary,  737 

of  portal  vein,  465 
Thymus  death,  532,  546 

gland,  diseases  of,  546 
Thyrocele,  534 

Thyroid  gland,  congestion  of,  536 
diseases  of,  534 

lingual,  546 

neoplasms  of,  545 
Thyroiditis,  acute,  536 
Tic,  convulsive,  819 

generalized,  S19 

impulsive,  819 

localized,  819 

simple,  819 

with  explosive  utterances,  819 
Tick  fever,  215 

intermittent,  32 
Ticks,  893 
Tinnitus  aurium,  804 

aetiology  of,  805 

treatment  of,  805 
Tobacco  poisoning,  323 

sjTTiptoms  of,  323 

treatment  of,  323 
Tongue,  diseases  of,  335 

eczema  of,  t,^;^ 

geographical,  335 

pityriasis  of,  335 
Tonsillar  abscess,  342 
Tonsillitis,  340 

acute  follicular,  340 
aetiology  of,  340 
definition  of,  340 
pathology  of,  341 
symptoms  of,  341 
treatment  of,  341 

acute  lacunar,  340 

acute  parenchymatous,  342 

acute  ulcerative,  340 

phlegmonous,  342 
Tonsils,  diseases  of,  33S 
Topical  diagnosis  of  cerebral  lesions,  746 
Torticollis,  or  wTy-neck,  278,  811 

congenital,  811 
pathology  of,  811 

spasmodic,  812 
treatment  of,  812 
Toxic  jaundice,  470 
Trachea,  diseases  of.  632 
Tracheo-bronchitis,  acute,  630 
Transverse  myelitis,  750 
Traumatic  hysteria,  847 

neuroses,  847 


93° 


INDEX. 


Traumatic  neuroses,  setiology  of,  847 
pathology  of,  848 
prognosis  of,  848 
symptoms  of,  848 
treatment  of,  848 
Trematodiasis,  870 
Trembles,  140 
Trichina  spiralis,  880 
Trichiniasis,  880 
Trichiuris  trichiura,  876 
Trichinosis,  880 
Trichocephalus  dispar,  876 
Tricuspid  insufficiency,  5  S3 
physical  signs  of,  583 

jugular  pulse,  583 
treatment  of,  593 
obstruction,  584 

physical  signs  of,  584 
treatment  of,  593 
Trifacial  nerve,  lesions  of,  800 
symptoms  of,  800 

paralysis  of  motor  portion  of  the,  800 
of  sensory  portion  of  the,  801 
treatment  of,  801 
Trional  poisoning,  318 
Trigeminus,  lesions  of,  800 
Trismus,  127 
Tropical  adenitis,  86 
bubo,  86 
dysentery,  72 
splenomegaly,  217 
Trousseau's  symptom,  834 
Trunecek's  serum,  609 
Trypanosoma  fever,  206 
gambiense,  206 
Evansi,  206 
Brucei,  206 
Trypanosomiasis,  206 

treatment  of,  207 
Tubercle,  157 

anatomy  and  history  of,  157 

calcareous  infiltration  of,  158 

caseation  of,  157 

degeneration  of,  157 

fibroid  change  in,  158 

histogenesis  of,  157 

retro-active  inflammation  caused  by,  i  s  7. 

158 
softening  of,  157 
Tubercular  peritonitis,  186 

ulcer  of  bowel,  411 
Tubercuhn  test  for  tuberculosis,  168 

treatment  by,  182 
Tuberculosis,  155 
aetiology  of,  155 
age,  156 
bacillus  of,  155 
climate,  156 
food,  156 
heredity,  156 
race,  156 
sanitation,  156 
sex,  156 


Tuberculosis,  shape  of  chest,  157 
traumatism,  157 
acute  general  miliary,  159 
diagnosis  of,  159 
prognosis  of,  160 
symptoms  of,  159 
treatment  of,  160 
acute    general   of  meningeal   form,   see 

tuberculous  meningitis,  729 
acute  general  of  pulmonary  form,  160 
diagnosis  of,  160 
physical  signs  of,  160 
symptoms  of,  160 
treatment  of,  161 
acute  miliary,  158 

pathology  of,  158 
acute  pneumonic  pulmonary,  161 
symptoms  of,  161 
treatment  of,  162 
types  of,  161 
chronic  pulmonary,  162 
diagnosis  of,  168 
pathology  of,  162 
physical  signs  of,  166 
prognosis  of,  170 
symptoms  of,  164 
chronic  ulcerative,  161 
diffuse  general,  158 
immunization  against,  173 
of  the  heart  and  blood-vessels,  190 
of  the  kidney,  188 

miliary  granulations  in,  188 
pathology  of,  188 
primary  foci  in,  188 
symptoms  of,  188 
treatment  of,  188 
of  the  lymphatic  glands,  184 
aetiology  of,  184 
diagnosis  of,  185 
prognosis  of,  185 
symptoms  of,  184 
tabes  mesenterica,  186 
treatment  of,  187 
of  the  mammary  glands,  190 
of    the    ovaries,    Fallopian    tubes     and 

uterus,  189 
of  the  pelvis  of  the  kidney,  ureters,  and 

bladder,  188 
of  the  pericardium,  187 
of  the  peritonaeum,  186 
of  the  pleura,  186 
of  the  serous  membranes,  186 
of  the  testicles,  prostate  gland,  and  sem- 
inal vesicles,  189 
pathology  of,  157 

degenerations  of  tubercle,  157 
secondary  inflammatory  processes,  158 
prophylaxis  of,  170 
pulmonary,  161 
treatment  of,  173 
by  tuberculin,  182 
climatic,  173 
dietetic,  176 


INDEX. 


931 


Tuberculosis,  treatment  of,  hygienic,  174 
medicinal,  17S 
of  symptoms  of,  180 
open  air,  175 
sanatorium,  175 
tent,  176 
ulcerative,  161 
Tuberculous  laryngitis,  627 
bronchial  lymph-nodes,  163 
broncho-pneumonia,  162 
cavities,  163 
lymphadenitis,  184 
meningitis,  729 
pleurisy,  163 
pneumonia,  163 
sputum,  165 

tumors  of  the  intestines,  432,  433 
ulceration  of  intestine,  primary,  411 
Tumors  of  the  spinal  cord  and  membranes, 
780 
symptoms  of  780 
treatment  of,  781 
varieties  of,  780 
Twelfth  nerve,  lesions  of,  813 
Typhlitis,  412 
Typhoid  fever,  see  enteric  fever,  7 

spine,  14 
Typhus  abdominalis,  7 
exanthematicus,  33 
fever.  ^;^ 

aetiology  of,  33 
clinical  chart  of,  35 
contagiousness,  34 
diagnosis  of,  36 
eruption  of,  35 
incubation  of,  34 
pathology  of,  34 
prognosis  of,  36 
symptoms  of,  34 
treatment  of,  36 
icteroides,  42 
tropicus,  42 
Tyrotoxismus,  326 

Ulcer,  embolic,  of  stomach,  358 

of  intestine,  412 
gastric,  35S 

aetiology  of,  358 

course  and  termination  of,  360 

definition  of,  358 

diagnosis  of,  360 

hsemorrhage,  359 

pathology  of,  359 

prognosis  of,  360 

symptoms  of,  359 

treatment  of,  361 
operative,  368 
of  duodenum,  410 

aetiology  of,  410 

pathology  of,  410 

prognosis  of,  410 

treatment  of,  411 
peptic,  358 


Ulcer,     peptic,    perforating,    of     stomach, 
358 

round,  of  stomach,  358 

syphilitic,  of  intestine,  412 

thrombotic,  of  stomach,  358 
Ulceration  of  the  bowel,  410 

primary  tuberculous  of  intestine,  411 
symptoms  of,  411 
treatment  of,  411 
Ulcerative  colitis,  396 

endocarditis,  569 
Ulcus  ventriculi,  358 
Uncinaria  Americana,  877 

duodenalis,  877 
Uncinariasis,  877 
Undulant  fever,  37 

Unilateral  progressive  facial  atrophy,  856 
Unschald's  sign,  267 
Uraemia,  681 

symptoms  of,  682 

treatment  of,  682 
Ureter,  tuberculosis  of,  188 
Uricacidaemia,  263 
Uricaemia,  263 

Urinary  system,  diseases  of,  674 
Urticaria,  giant,  853 
Uterus,  tuberculosis  of,  189 

Vaccination,  254 

compUcations  of,  255 
operation  of,  254 
symptoms  following,  254 
Vaccine  disease,  253 
Vaccinia,  253 

bacteriology  of,  253 
disease,  humanized  lymph  in,  254 
generalized,  255 
phenomena  of,  254 
rashes,  255 
nature  of,  255 
treatment  of,  255 
Vagus  nerve,  lesions  of,  807 
Valvular  (cardiac)  defects,  574 
congenital,  586 
pathology,  574 
relative  frequency  of,  575 
disease,  chronic,  prognosis  of,  5S7 
treatment  of,  587 
of  dropsy,  597 
of  dyspnoea,  596 

of  irregularities  of  heart  action  and 
palpitations,  597 
lesions,  associated  or  combined,  586 
Valvulitis,  574 
Vaquez's  disease,  517 
Varicella,  240 
aetiology  of,  240 
diagnosis  of,  241 
prognosis  of,  241 
symptoms  of,  240 
treatment  of,  241 
Variola,  242 
Variolae  sine  variolis,  246 


932 


INDEX. 


Vaso-motor  and  trophic  derangements,  851 

rhinitis,  621 
Veronal  poisoning,  319 

sjTnptoms  of,  319 

treatment  of,  319 
Verruga,  223 

Vesicular  emphysema,  645 
Vinegar  eel,  876 
Visceroptosis,  379 

aetiology  of,  380 

definition  of,  379 

symptoms  of,  380 

treatment  of,  380 
Vocal  cord,  paralysis  of,  808 
Volvulus,  418 
Vomiting,  cyclic,  392 
Von  Graefe's  sign,  537 

Wahl's  sign,  418 
Waxy  kidney,  702 

liver,  451 
Weil's  disease,  212 

aetiology  of,  212 

diagnosis  of,  212 

pathology  of,  212 

prognosis  of,  212 

symptoms  of,  212 

treatment  of,  212 
Wernicke's  test,  796 
Wet  brain,  311 
Whooping-cough,  99 

aetiology  of.  99 

complications  and  sequelae  of,  loi 

diagnosis  of,  loi 

pathology  of,  100 

prognosis  of,  10 1 

symptoms  of,  100 

treatment  of,  10 1 
Widal  reaction,  15 


Winckel's  disease,  521 

Wintrich's  sign,  168 
Wood  alcohol  poisoning,  315 
Wool-sorter's  disease,  133,  135 
Word  blindness,  741 
Word-deafness,  741 
Worms,  870,  872 

bladder,  463 

flat,  887 

guinea,  885 

hook,  877 

maw,  872 

pin,  874 

round,  872 

seat,  874 

thread,  874 
Writer's  cramp,  849 

aetiology  of,  849 

symptoms  of,  849 

treatment  of,  850 
Wry-neck,  811 

Xerostomia,  337 

Yaws,  222 

Yellow  atrophy  of  the  liver,  acute,  444 
fever,  42 

aetiology  of,  42 

albuminuria  in,  44 

clinical  chart  of,  44 

diagnosis  of,  44 

jaundice  in,  43 

mosquitoes  and,  42,  45 

pathology  of,  42 

prognosis  of,  41 

prophylaxis  of,  45 

slow  pulse  of,  43 

symptoms  of,  43 

treatment  of,  45 
by  serum,  47 


